Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DE00005551 | WA |
NPI | 1083670780 |
---|---|
Provider Name | Dr. Mark David Carlson |
First Address | Tacoma, WA 98405-1946 |
Second Address | Tacoma, WA 98405-1946 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5005491 | (05) | WA |
T02860 | (02) |