MEDICARE: CHARLES T. MCCARROLL D.D.S.

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	122300000X	Dentist	BM2319932	IN

General Provider Information

NPI Number	:	1174617237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES T. MCCARROLL D.D.S.

Provider Business Mailing Address
First Line	:	10033 WICKER AVE STE 9
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8777
Country	:	US
Telephone Number	:	219-365-9750
Fax Number	:	219-365-9845

Provider Business Practice Location Address
First Line	:	10033 WICKER AVE STE 9
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8777
Country	:	US
Telephone Number	:	219-365-9750
Fax Number	:	219-365-9845

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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