Healthcare Provider Details

I. General information

NPI: 1205192663
Provider Name (Legal Business Name): JACOB R CARROLL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20100 N 51ST AVE SUITE C-310
GLENDALE AZ
85308-5125
US

IV. Provider business mailing address

20100 N 51ST AVE SUITE C-310
GLENDALE AZ
85308-5125
US

V. Phone/Fax

Practice location:
  • Phone: 623-572-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD9440
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: