Healthcare Provider Details

I. General information

NPI: 1053606970
Provider Name (Legal Business Name): TINA L CARLSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COURT ST STE 270
LEBANON NH
03766-6313
US

IV. Provider business mailing address

PO BOX 554
SOUTH ROYALTON VT
05068-0554
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-1830
  • Fax:
Mailing address:
  • Phone: 802-779-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2954
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: