Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D11193 | MN |
NPI | 1003932138 |
---|---|
Provider Name | Dr. Tricia Carlson |
First Address | Wyoming, MN 55092-0845 |
Second Address | Wyoming, MN 55092-8353 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2007 |
Last Update Date | 08/07/2007 |