Provider Demographics
NPI:1952369720
Name:ETHEREDGE, CAROLYN A (DMD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:A
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:A
Other - Last Name:BRUSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6604 MESA DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-2706
Mailing Address - Country:US
Mailing Address - Phone:512-965-5347
Mailing Address - Fax:512-255-3898
Practice Address - Street 1:3631 N HILLS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3000
Practice Address - Country:US
Practice Address - Phone:512-345-2425
Practice Address - Fax:512-345-3898
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010189221223G0001X
TX24282122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice