Healthcare Provider Details

I. General information

NPI: 1992859441
Provider Name (Legal Business Name): JOEL THOMAS CARROLL DDS PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 LEONARD ST NW SUITE 202
GRAND RAPIDS MI
49534
US

IV. Provider business mailing address

4310 LEONARD ST NW SUITE 202
GRAND RAPIDS MI
49534
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-6323
  • Fax: 616-453-0012
Mailing address:
  • Phone: 616-453-6323
  • Fax: 616-453-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number150220
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: