Individual
ASA DERRICK CARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
25 E WASHINGTON ST, CHICAGO, IL 60602-1708
(312) 782-8862
Mailing address
1517 W TAYLOR ST FL 1, CHICAGO, IL 60607-4015
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019031149
IL
Other
Enumeration date
06/05/2017
Last updated
06/05/2017
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