=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407904147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN THOMAS CARSON SR. D.D.S. M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10425 FAIR OAKS BLVD SUITE 102
-----------------------------------------------------
City | FAIR OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95628-7559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-965-7444
-----------------------------------------------------
Fax | 916-965-9372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10425 FAIR OAKS BLVD SUITE 102
-----------------------------------------------------
City | FAIR OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95628-7559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-965-7444
-----------------------------------------------------
Fax | 916-965-9372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 32042
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------