Provider Demographics
NPI:1508873282
Name:CARLSON, RANDY DENNIS (DMD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DENNIS
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5256 S MISSION RD
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-3624
Mailing Address - Country:US
Mailing Address - Phone:760-630-5500
Mailing Address - Fax:760-630-5831
Practice Address - Street 1:5256 S MISSION RD
Practice Address - Street 2:SUITE 1101
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-3624
Practice Address - Country:US
Practice Address - Phone:760-630-5500
Practice Address - Fax:760-630-5831
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
34679OtherDELTA DENTAL
415674OtherUNITED CONCORDIA