Provider Demographics
NPI:1164425146
Name:CAROSELLO, STEPHEN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:CAROSELLO
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 1:9500 MENTOR AVE
Mailing Address - Street 2:STE 280
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8715
Mailing Address - Country:US
Mailing Address - Phone:440-352-2887
Mailing Address - Fax:440-352-7611
Practice Address - Street 1:9500 MENTOR AVE
Practice Address - Street 2:STE 280
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8715
Practice Address - Country:US
Practice Address - Phone:440-352-2887
Practice Address - Fax:440-352-7611
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-40531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0475481Medicaid