Provider Demographics
NPI:1700963931
Name:CARSON, JEFFREY A (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:CARSON
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 1:2175 CHAMBLISS AVE NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3842
Mailing Address - Country:US
Mailing Address - Phone:423-479-5966
Mailing Address - Fax:
Practice Address - Street 1:2175 CHAMBLISS AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3842
Practice Address - Country:US
Practice Address - Phone:423-479-5966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0113541223G0001X
TNDS71041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice