Provider Demographics
NPI:1376607184
Name:CARLSON, GRACE YU (DDS)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:YU
Last Name:CARLSON
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 1:35225 AVENUE A
Mailing Address - Street 2:SUITE 201
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4359
Mailing Address - Country:US
Mailing Address - Phone:909-790-2618
Mailing Address - Fax:909-797-5781
Practice Address - Street 1:35225 AVENUE A
Practice Address - Street 2:SUITE 201
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4359
Practice Address - Country:US
Practice Address - Phone:909-790-2618
Practice Address - Fax:909-797-5781
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist