Healthcare Provider Details

I. General information

NPI: 1104710755
Provider Name (Legal Business Name): CARSON THEODORE HUNT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 3RD AVE STE 201
SAN DIEGO CA
92103-2129
US

IV. Provider business mailing address

2469 PURDUE AVE APT 203
LOS ANGELES CA
90064-5111
US

V. Phone/Fax

Practice location:
  • Phone: 619-298-2322
  • Fax:
Mailing address:
  • Phone: 530-966-1745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number111448
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: