Provider Demographics
NPI:1609893304
Name:CARSON, JOHN ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:CARSON
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 1:7415 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3477
Mailing Address - Country:US
Mailing Address - Phone:520-514-7203
Mailing Address - Fax:
Practice Address - Street 1:7415 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3477
Practice Address - Country:US
Practice Address - Phone:520-514-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD53961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0476680Medicare UPIN
AZ01465743Medicare UPIN