Provider Demographics
NPI:1902223886
Name:CARLSON, CHUCK (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHUCK
Middle Name:
Last Name:CARLSON
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 1:3110 SAWTELLE BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1432
Mailing Address - Country:US
Mailing Address - Phone:949-280-2424
Mailing Address - Fax:
Practice Address - Street 1:3110 SAWTELLE BLVD APT 207
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-1432
Practice Address - Country:US
Practice Address - Phone:949-280-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA631041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics