Provider Demographics
NPI:1306042882
Name:CARLSON, LEONARD G (DDS)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:G
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 N HOLLYWOOD WAY
Mailing Address - Street 2:#102
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-841-5776
Mailing Address - Fax:818-841-5470
Practice Address - Street 1:847 N HOLLYWOOD WAY
Practice Address - Street 2:#102
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-841-5776
Practice Address - Fax:818-841-5470
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice