Provider Demographics
NPI:1083971352
Name:CARLSON, SEAN KENNETH (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:KENNETH
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:163 MILLER AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2759
Mailing Address - Country:US
Mailing Address - Phone:415-388-2970
Mailing Address - Fax:415-388-2999
Practice Address - Street 1:163 MILLER AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2759
Practice Address - Country:US
Practice Address - Phone:415-388-2970
Practice Address - Fax:415-388-2999
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA420371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics