Basic Information
Provider Information | |||||||||
NPI: | 1508873282 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLSON | ||||||||
FirstName: | RANDY | ||||||||
MiddleName: | DENNIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5256 S MISSION RD | ||||||||
Address2: | SUITE 1101 | ||||||||
City: | BONSALL | ||||||||
State: | CA | ||||||||
PostalCode: | 920033624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7606305500 | ||||||||
FaxNumber: | 7606305831 | ||||||||
Practice Location | |||||||||
Address1: | 5256 S MISSION RD | ||||||||
Address2: | SUITE 1101 | ||||||||
City: | BONSALL | ||||||||
State: | CA | ||||||||
PostalCode: | 920033624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7606305500 | ||||||||
FaxNumber: | 7606305831 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 34679 | CA | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 34679 | 01 |   | DELTA DENTAL | OTHER | 415674 | 01 |   | UNITED CONCORDIA | OTHER |