Provider Demographics
NPI:1407904147
Name:CARSON, JOHN THOMAS SR (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:CARSON
Suffix:SR
Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:10425 FAIR OAKS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7559
Mailing Address - Country:US
Mailing Address - Phone:916-965-7444
Mailing Address - Fax:916-965-9372
Practice Address - Street 1:10425 FAIR OAKS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7559
Practice Address - Country:US
Practice Address - Phone:916-965-7444
Practice Address - Fax:916-965-9372
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA320421223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics