MEDICARE: DR. BRIAN R. CARROLL DDS

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	12317	MI

General Provider Information

NPI Number	:	1447399175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN R. CARROLL DDS

Provider Business Mailing Address
First Line	:	34405 GRAND RIVER AVE
Second Line	:
City	:	FARMINGTON
State	:	MI
Zip	:	48335-3309
Country	:	US
Telephone Number	:	248-478-3285
Fax Number	:	248-478-9398

Provider Business Practice Location Address
First Line	:	34405 GRAND RIVER AVE
Second Line	:
City	:	FARMINGTON
State	:	MI
Zip	:	48335-3309
Country	:	US
Telephone Number	:	248-478-3285
Fax Number	:	248-478-9398

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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