=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043796873
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT CARLSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2018
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 E RED BRIDGE RD STE 321
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64131-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-943-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5309 W 64TH ST
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66208-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-228-4913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 61335
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2018014355
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------