Provider Demographics
NPI:1609076587
Name:CARROLL, LEE VAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:VAN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 W MAIN ST
Mailing Address - Street 2:STE. 2
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1343
Mailing Address - Country:US
Mailing Address - Phone:334-793-7687
Mailing Address - Fax:334-793-0067
Practice Address - Street 1:1805 W MAIN ST
Practice Address - Street 2:STE. 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1343
Practice Address - Country:US
Practice Address - Phone:334-793-7687
Practice Address - Fax:334-793-0067
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4080AL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics