Provider Demographics
NPI:1053606970
Name:CARLSON, TINA L (RDH)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:SOUTH ROYALTON
Mailing Address - State:VT
Mailing Address - Zip Code:05068-0554
Mailing Address - Country:US
Mailing Address - Phone:802-779-4010
Mailing Address - Fax:
Practice Address - Street 1:1 COURT ST STE 270
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-6313
Practice Address - Country:US
Practice Address - Phone:603-448-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2954124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2954OtherRDH