Healthcare Provider Details

I. General information

NPI: 1265229017
Provider Name (Legal Business Name): CARSON LAIL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 HIGHWAY 120
DULUTH GA
30096-3354
US

IV. Provider business mailing address

3148 HIGHWAY 120
DULUTH GA
30096-3672
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-2400
  • Fax:
Mailing address:
  • Phone: 678-761-5829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: