Healthcare Provider Details

I. General information

NPI: 1770102097
Provider Name (Legal Business Name): ROBERT CARROLL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5953 WESCOTT RD
COLUMBIA SC
29212-2717
US

IV. Provider business mailing address

755 RIVER RD
COLUMBIA SC
29212-8809
US

V. Phone/Fax

Practice location:
  • Phone: 803-781-5225
  • Fax:
Mailing address:
  • Phone: 38-518-7564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10415
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: