Provider Demographics
NPI:1144329665
Name:BRYAN, CARLA PETERSON (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:PETERSON
Last Name:BRYAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 CAMINO DE LAS MARES
Mailing Address - Street 2:SUITE 138
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673
Mailing Address - Country:US
Mailing Address - Phone:949-487-6780
Mailing Address - Fax:949-487-6781
Practice Address - Street 1:657 CAMINO DE LAS MARES
Practice Address - Street 2:SUITE 138
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-487-6780
Practice Address - Fax:949-487-6781
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADV353621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice