Healthcare Provider Details

I. General information

NPI: 1215916291
Provider Name (Legal Business Name): JOHN RAYMOND CARLSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 COURT ST
MIDDLEBURY VT
05753-1419
US

IV. Provider business mailing address

7 CHIPMAN HTS
MIDDLEBURY VT
05753-1201
US

V. Phone/Fax

Practice location:
  • Phone: 802-388-6344
  • Fax: 802-388-4103
Mailing address:
  • Phone: 802-388-3874
  • Fax: 802-388-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number016-0000741
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: