Provider Demographics
NPI:1588969547
Name:RANDY D CARLSON DMD ADC AND CHARLES L DRURY DDS AEGD APC
Entity type:Organization
Organization Name:RANDY D CARLSON DMD ADC AND CHARLES L DRURY DDS AEGD APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:760-630-5500
Mailing Address - Street 1:5256 S MISSION RD
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-3614
Mailing Address - Country:US
Mailing Address - Phone:760-630-5500
Mailing Address - Fax:760-630-5831
Practice Address - Street 1:5256 S MISSION RD
Practice Address - Street 2:SUITE 1101
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-3614
Practice Address - Country:US
Practice Address - Phone:760-630-5500
Practice Address - Fax:760-630-5831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489051223G0001X
CA346791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34679OtherDELTA DENTAL
CA753898OtherUNITED CONCORDIA
CA48905OtherDELTA DENTAL
CA415674OtherUNITED CONCORDIA