Provider Demographics
NPI:1124035787
Name:CARSON, KATHLEEN SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:SUSAN
Last Name:CARSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30200 AGOURA ROAD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4031
Mailing Address - Country:US
Mailing Address - Phone:818-889-0400
Mailing Address - Fax:818-889-9032
Practice Address - Street 1:30200 AGOURA ROAD
Practice Address - Street 2:SUITE 270
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4031
Practice Address - Country:US
Practice Address - Phone:818-889-0400
Practice Address - Fax:818-889-9032
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist