Provider Demographics
NPI:1811032071
Name:CARSON, JOHN MONTGOMERY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MONTGOMERY
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 1:2199 CHEAT RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4451
Mailing Address - Country:US
Mailing Address - Phone:304-594-9733
Mailing Address - Fax:304-594-3498
Practice Address - Street 1:2199 CHEAT RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-4451
Practice Address - Country:US
Practice Address - Phone:304-594-9733
Practice Address - Fax:304-594-3498
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV23301223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVCA0524605Medicare ID - Type Unspecified
WVT32347Medicare UPIN