Provider Demographics
NPI:1023043031
Name:CARROLL, THOMAS MARK (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARK
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:9651 BREWERTON RD
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-0189
Mailing Address - Country:US
Mailing Address - Phone:315-676-7900
Mailing Address - Fax:315-676-7108
Practice Address - Street 1:9651 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-0189
Practice Address - Country:US
Practice Address - Phone:315-676-7900
Practice Address - Fax:315-676-7108
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3T393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist