MEDICARE: CARROLL FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1831782192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARROLL FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	4310 LEONARD ST NW STE 202
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-8447
Country	:	US
Telephone Number	:	616-453-6323
Fax Number	:	616-453-0012

Provider Business Practice Location Address
First Line	:	4310 LEONARD ST NW STE 202
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-8447
Country	:	US
Telephone Number	:	616-453-6323
Fax Number	:	616-453-0012

Authorized Official
Title or Position	:	DOCTOR
Name	:	JOEL T CARROLL
Credential	:
Telephone Number	:	616-453-6323

Provider Enumeration Date	:	02/18/2021
Last Update Date	:	02/18/2021

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Directions to “CARROLL FAMILY DENTISTRY ” Practice Location

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