=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376816496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES LARKIN O'CARROLL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2012
-----------------------------------------------------
Last Update Date | 02/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 LEE ST
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-4584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-296-8111
-----------------------------------------------------
Fax | 847-296-8113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 712 LEE ST
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-4584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-296-8111
-----------------------------------------------------
Fax | 847-296-8113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.0198899
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------