Provider Demographics
NPI:1184629453
Name:CAROLAN, KEVIN BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRUCE
Last Name:CAROLAN
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 1:901 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010126771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice