=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205176468
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR CARLA BRYAN DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2013
-----------------------------------------------------
Last Update Date | 02/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 657 CAMINO DE LOS MARES STE 138
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-487-6780
-----------------------------------------------------
Fax | 949-487-6781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 657 CAMINO DE LOS MARES STE 138
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-487-6780
-----------------------------------------------------
Fax | 949-487-6781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CARLA PETERSON BRYAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-487-6780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DV25362
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------