MEDICARE: DR. GARY LEROY CARLSON D.D.S., M.S.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	D6852	MN

General Provider Information

NPI Number	:	1376609412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LEROY CARLSON D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	17809 HUTCHINS DR
Second Line	:	STE 101
City	:	MINNETONKA
State	:	MN
Zip	:	55345-4100
Country	:	US
Telephone Number	:	952-474-3203
Fax Number	:	952-474-3204

Provider Business Practice Location Address
First Line	:	17809 HUTCHINS DR
Second Line	:	STE 101
City	:	MINNETONKA
State	:	MN
Zip	:	55345-4100
Country	:	US
Telephone Number	:	952-474-3203
Fax Number	:	952-474-3204

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2006
Last Update Date	:	12/07/2025

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