Healthcare Provider Details

I. General information

NPI: 1598011561
Provider Name (Legal Business Name): CARSON FAMILY DENTISTRY, PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 CHESTNUT ST BOX 567
SPRINGFIELD SD
57062
US

IV. Provider business mailing address

707 CHESTNUT ST BOX 567
SPRINGFIELD SD
57062
US

V. Phone/Fax

Practice location:
  • Phone: 605-369-2226
  • Fax:
Mailing address:
  • Phone: 605-369-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberM894
License Number StateSD

VIII. Authorized Official

Name: DR. CL;ARENCE NOLAN CARSON III
Title or Position: OWNER, DENTIST
Credential: DDS
Phone: 605-369-2226