Provider Demographics
NPI:1205176468
Name:DR CARLA BRYAN DDS
Entity type:Organization
Organization Name:DR CARLA BRYAN DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:PETERSON
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-487-6780
Mailing Address - Street 1:657 CAMINO DE LOS MARES STE 138
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2810
Mailing Address - Country:US
Mailing Address - Phone:949-487-6780
Mailing Address - Fax:949-487-6781
Practice Address - Street 1:657 CAMINO DE LOS MARES STE 138
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2810
Practice Address - Country:US
Practice Address - Phone:949-487-6780
Practice Address - Fax:949-487-6781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADV25362122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty