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General NPI Number Information
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NPI Number | 1164697066
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Entity Type | Individual
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Provider Name | RUSSELL EDGAR CARLSON III DDS
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Gender | Male
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Dates
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Enumeration Date | 04/23/2008
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Last Update Date | 04/23/2008
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Provider Practice Location Address
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Address Line | 1145 66TH ST SUITE 2
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City | WINDSOR HEIGHTS
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State | IA
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Zip | 50311-1705
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Country | US
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Telephone | 515-279-0856
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Fax | 515-255-6907
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Provider Business Mailing Address
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Address Line | 1145 66TH ST SUITE 2
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City | WINDSOR HEIGHTS
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State | IA
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Zip | 50311-1705
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Country | US
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Telephone | 515-279-0856
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Fax | 515-255-6907
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6535
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License Number State | IA
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