Provider Demographics
NPI:1649056193
Name:CARLSTON DENTAL GROUP
Entity type:Organization
Organization Name:CARLSTON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAIMAA
Authorized Official - Middle Name:
Authorized Official - Last Name:EWIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-838-0844
Mailing Address - Street 1:2472 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3334
Mailing Address - Country:US
Mailing Address - Phone:310-838-0844
Mailing Address - Fax:310-838-9758
Practice Address - Street 1:2472 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-3334
Practice Address - Country:US
Practice Address - Phone:310-838-0844
Practice Address - Fax:310-838-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty