Healthcare Provider Details

I. General information

NPI: 1609076587
Provider Name (Legal Business Name): LEE VAN CARROLL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 W MAIN ST STE. 2
DOTHAN AL
36301-1343
US

IV. Provider business mailing address

1805 W MAIN ST STE. 2
DOTHAN AL
36301-1343
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-7687
  • Fax: 334-793-0067
Mailing address:
  • Phone: 334-793-7687
  • Fax: 334-793-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4080AL
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: