Provider Demographics
NPI:1164778346
Name:CAROLAN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CAROLAN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:CAROLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-982-7682
Mailing Address - Street 1:901 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3746
Mailing Address - Country:US
Mailing Address - Phone:810-982-7682
Mailing Address - Fax:810-984-2653
Practice Address - Street 1:901 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3746
Practice Address - Country:US
Practice Address - Phone:810-982-7682
Practice Address - Fax:810-984-2653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty