MEDICARE: DR. PETER J CARROLL DENTIST

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	DS022959L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	732043	OTHER	PA	U/C PROVIDER NUMBER

General Provider Information

NPI Number	:	1558307215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER J CARROLL DENTIST

Provider Business Mailing Address
First Line	:	7946 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3321
Country	:	US
Telephone Number	:	215-725-8901
Fax Number	:	215-725-8951

Provider Business Practice Location Address
First Line	:	7946 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3321
Country	:	US
Telephone Number	:	215-725-8901
Fax Number	:	215-725-8951

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

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	07/08/2007

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