Healthcare Provider Details

I. General information

NPI: 1649956541
Provider Name (Legal Business Name): EMILY CARROLL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473
US

IV. Provider business mailing address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0364
  • Fax:
Mailing address:
  • Phone: 573-596-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN28079
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: