Provider Demographics
NPI:1376704825
Name:STEPHEN T CAROSELLO DDS INC
Entity Type:Organization
Organization Name:STEPHEN T CAROSELLO DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAROSELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-352-2887
Mailing Address - Street 1:9500 MENTOR AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8713
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:SUITE 280
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8713
Practice Address - Country:US
Practice Address - Phone:440-352-2887
Practice Address - Fax:440-352-7611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30014053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0475481Medicaid