Provider Demographics
NPI:1336207679
Name:CARLSON, MICHAEL JEFFREY (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFREY
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 1:726 E GRAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025
Mailing Address - Country:US
Mailing Address - Phone:760-747-2616
Mailing Address - Fax:760-738-0400
Practice Address - Street 1:726 E GRAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-747-2616
Practice Address - Fax:760-738-0400
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist