Provider Demographics
NPI:1629271564
Name:ROBERT CARROLL, DDS, PC
Entity Type:Organization
Organization Name:ROBERT CARROLL, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:GENERAL DENTIST
Authorized Official - Phone:573-365-6600
Mailing Address - Street 1:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-0827
Mailing Address - Country:US
Mailing Address - Phone:573-365-6600
Mailing Address - Fax:573-365-6470
Practice Address - Street 1:2935 BAGNELL DAM BLVD
Practice Address - Street 2:STE. 102
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-8661
Practice Address - Country:US
Practice Address - Phone:573-365-6600
Practice Address - Fax:573-365-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073532800OtherTYPE 1 NPI