Healthcare Provider Details

I. General information

NPI: 1760614481
Provider Name (Legal Business Name): CLAYTON DALE KARLSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3919 N MAPLE ST
SPOKANE WA
99205-1349
US

IV. Provider business mailing address

611 N IRON BRIDGE WAY
SPOKANE WA
99202-4932
US

V. Phone/Fax

Practice location:
  • Phone: 509-444-8200
  • Fax:
Mailing address:
  • Phone: 509-444-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60400620
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4236
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: