=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558713693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN CARSON DDS MS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2016
-----------------------------------------------------
Last Update Date | 07/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10425 FAIR OAKS BLVD STE 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 STE 102
-----------------------------------------------------
City | FAIR OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95628-7559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-965-7444
-----------------------------------------------------
Fax | 916-965-9372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN THOMAS CARSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 916-965-7444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | CA32042
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------