Provider Demographics
NPI:1629297130
Name:CARSON, CARLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ALDEN ST.
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016
Mailing Address - Country:US
Mailing Address - Phone:908-276-1669
Mailing Address - Fax:908-276-1631
Practice Address - Street 1:15 ALDEN ST.
Practice Address - Street 2:SUITE #6
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016
Practice Address - Country:US
Practice Address - Phone:908-276-1669
Practice Address - Fax:908-276-1631
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02327700122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D08968400OtherCDS
NJFC0002648OtherCDS
NJ22DI02327700OtherDENTAL LIC