MEDICARE: DR. THOMAS WILLIAM CARLSON DDS

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	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1427010495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS WILLIAM CARLSON DDS

Provider Business Mailing Address
First Line	:	3001 A SIXTH ST.
Second Line	:	NAVAL HEALTH CLINIC
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-0000
Country	:	US
Telephone Number	:	847-688-2755
Fax Number	:	847-688-2546

Provider Business Practice Location Address
First Line	:	3001 A SIXTH ST.
Second Line	:	NAVAL HEALTH CLINIC
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-0000
Country	:	US
Telephone Number	:	847-688-2755
Fax Number	:	847-688-2546

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

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	11/01/2007

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