Provider Demographics
NPI:1902965890
Name:CARLSON, ERIC TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:TODD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12725 43RD ST NE STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4929
Mailing Address - Country:US
Mailing Address - Phone:763-497-2367
Mailing Address - Fax:763-497-8171
Practice Address - Street 1:12725 43RD ST NE STE 202
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4929
Practice Address - Country:US
Practice Address - Phone:763-497-2367
Practice Address - Fax:763-497-8171
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN58492400Medicaid