Provider Demographics
NPI:1184889990
Name:CARLSON, GREGORY MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARK
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 1:2955 OCEAN ST
Mailing Address - Street 2:APT 17
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2954
Mailing Address - Country:US
Mailing Address - Phone:760-434-8341
Mailing Address - Fax:
Practice Address - Street 1:2955 OCEAN STREET
Practice Address - Street 2:APT 17
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:406-338-6292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT270074Medicaid