Provider Demographics
NPI:1720417041
Name:CARSON, CODY (LD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:CARSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2411
Mailing Address - Country:US
Mailing Address - Phone:360-676-1499
Mailing Address - Fax:360-738-2281
Practice Address - Street 1:2710 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2411
Practice Address - Country:US
Practice Address - Phone:360-676-1499
Practice Address - Fax:360-738-2281
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN 60404068122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist