Basic Information
| Provider Information | |||||||||
| NPI: | 1588969547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RANDY D CARLSON DMD ADC AND CHARLES L DRURY DDS AEGD APC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5256 S MISSION RD | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | BONSALL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920033614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606305500 | ||||||||
| FaxNumber: | 7606305831 | ||||||||
| Practice Location | |||||||||
| Address1: | 5256 S MISSION RD | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | BONSALL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920033614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606305500 | ||||||||
| FaxNumber: | 7606305831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2011 | ||||||||
| LastUpdateDate: | 01/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | DENNIS | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7606305500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 48905 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | 34679 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 34679 | 01 | CA | DELTA DENTAL | OTHER | 753898 | 01 | CA | UNITED CONCORDIA | OTHER | 48905 | 01 | CA | DELTA DENTAL | OTHER | 415674 | 01 | CA | UNITED CONCORDIA | OTHER |