Provider Demographics
NPI:1275756488
Name:CHRISTOPHER E CARROLL
Entity Type:Organization
Organization Name:CHRISTOPHER E CARROLL
Other - Org Name:PEDIATRIC DENTAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:507-452-1543
Mailing Address - Street 1:150 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3512
Mailing Address - Country:US
Mailing Address - Phone:507-452-1543
Mailing Address - Fax:507-452-6874
Practice Address - Street 1:150 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3512
Practice Address - Country:US
Practice Address - Phone:507-452-1543
Practice Address - Fax:507-452-6874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN84051223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4822990OtherMN TAX ID
WI33461700Medicaid
WI33461700Medicaid