Healthcare Provider Details

I. General information

NPI: 1528286010
Provider Name (Legal Business Name): PATRICK M CARROLL DMD PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7513 NEW LAGRANGE RD
LOUISVILLE KY
40222-4859
US

IV. Provider business mailing address

7513 NEW LAGRANGE RD
LOUISVILLE KY
40222-4859
US

V. Phone/Fax

Practice location:
  • Phone: 502-423-7868
  • Fax: 502-327-7446
Mailing address:
  • Phone: 502-423-7868
  • Fax: 502-327-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5551
License Number StateKY

VIII. Authorized Official

Name: DR. PATRCIK M CARROLL CARROLL
Title or Position: PRESIDENT
Credential: DMD
Phone: 502-423-7868