Provider Demographics
NPI:1568527703
Name:CARLSEN, GARY DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DAVID
Last Name:CARLSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17822 BEACH BLVD STE 342
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-7518
Mailing Address - Country:US
Mailing Address - Phone:714-847-6044
Mailing Address - Fax:714-842-3145
Practice Address - Street 1:17822 BEACH BLVD STE 342
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7518
Practice Address - Country:US
Practice Address - Phone:714-847-6044
Practice Address - Fax:714-842-3145
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA218561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery