Provider Demographics
NPI:1245962034
Name:CARLSON, SELAM TEGEGNE
Entity type:Individual
Prefix:
First Name:SELAM
Middle Name:TEGEGNE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2740
Mailing Address - Country:US
Mailing Address - Phone:210-295-5000
Mailing Address - Fax:
Practice Address - Street 1:2940 STANLEY RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-2740
Practice Address - Country:US
Practice Address - Phone:620-617-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist