Healthcare Provider Details

I. General information

NPI: 1487994406
Provider Name (Legal Business Name): KATHLEEN CARSON DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30200 AGOURA RD SUITE 270
AGOURA HILLS CA
91301-5434
US

IV. Provider business mailing address

30200 AGOURA RD SUITE 270
AGOURA HILLS CA
91301-5434
US

V. Phone/Fax

Practice location:
  • Phone: 818-889-0400
  • Fax: 818-889-9032
Mailing address:
  • Phone: 818-889-0400
  • Fax: 818-889-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number48708
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHLEEN CARSON
Title or Position: OWNER
Credential: DDS
Phone: 818-889-0400