Healthcare Provider Details

I. General information

NPI: 1023043031
Provider Name (Legal Business Name): THOMAS MARK CARROLL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9651 BREWERTON RD
BREWERTON NY
13029-0189
US

IV. Provider business mailing address

PO BOX 189 9651 BREWERTON RD
BREWERTON NY
13029-0189
US

V. Phone/Fax

Practice location:
  • Phone: 315-676-7900
  • Fax: 315-676-7108
Mailing address:
  • Phone: 315-676-7900
  • Fax: 315-676-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3T393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: