Provider Demographics
NPI:1104965979
Name:CARLSON, PAUL HOWARD (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:HOWARD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 SUNSET BLVD # B
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4715
Mailing Address - Country:US
Mailing Address - Phone:803-791-4398
Mailing Address - Fax:
Practice Address - Street 1:2315 SUNSET BLVD # B
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4715
Practice Address - Country:US
Practice Address - Phone:803-791-4398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist