=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467873331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY WILLIAM CARR BS, DMD, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2013
-----------------------------------------------------
Last Update Date | 12/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8735 TRAUTWEIN RD
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-9474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-776-1330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8735 TRAUTWEIN RD
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-9474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-776-1330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 63167
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------