1073532800 NPI number — DR. ROBERT EARL CARROLL GENERAL DENTIST

Table of content: DR. ROBERT EARL CARROLL GENERAL DENTIST (NPI 1073532800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073532800 NPI number — DR. ROBERT EARL CARROLL GENERAL DENTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
ROBERT
Provider Middle Name:
EARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
GENERAL DENTIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073532800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 827
Provider Second Line Business Mailing Address:
2935 BAGNELL DAM BLVD. STE. 102
Provider Business Mailing Address City Name:
LAKE OZARK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65049-0827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-365-6600
Provider Business Mailing Address Fax Number:
573-365-6470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2935 BAGNELL DAM BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE OZARK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65049-8661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-365-6600
Provider Business Practice Location Address Fax Number:
573-365-6470
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  MO13964 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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