MEDICARE: CAROLAN FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1164778346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLAN FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	901 SUPERIOR ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3746
Country	:	US
Telephone Number	:	810-982-7682
Fax Number	:	810-984-2653

Provider Business Practice Location Address
First Line	:	901 SUPERIOR ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3746
Country	:	US
Telephone Number	:	810-982-7682
Fax Number	:	810-984-2653

Authorized Official
Title or Position	:	CEO
Name	:	KEVIN B CAROLAN
Credential	:	D.D.S.
Telephone Number	:	810-982-7682

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	07/25/2012

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Directions to “CAROLAN FAMILY DENTISTRY ” Practice Location

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