Healthcare Provider Details

I. General information

NPI: 1831782192
Provider Name (Legal Business Name): CARROLL FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 LEONARD ST NW STE 202
GRAND RAPIDS MI
49534-8447
US

IV. Provider business mailing address

4310 LEONARD ST NW STE 202
GRAND RAPIDS MI
49534-8447
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOEL T CARROLL
Title or Position: DOCTOR
Credential:
Phone: 616-453-6323