Healthcare Provider Details

I. General information

NPI: 1083670780
Provider Name (Legal Business Name): MARK DAVID CARLSON MS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 SOUTH UNION AVENUE SUITE 250
TACOMA WA
98405-1946
US

IV. Provider business mailing address

1550 SOUTH UNION AVENUE SUITE 250
TACOMA WA
98405-1946
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-4601
  • Fax: 253-572-4769
Mailing address:
  • Phone: 253-572-4601
  • Fax: 253-572-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE00005551
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: