Provider Demographics
NPI:1659691319
Name:CARROLL, KELDON MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELDON
Middle Name:MICHAEL
Last Name:CARROLL
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 1:1116 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2336
Mailing Address - Country:US
Mailing Address - Phone:406-363-2200
Mailing Address - Fax:
Practice Address - Street 1:1116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2336
Practice Address - Country:US
Practice Address - Phone:406-363-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT174911223G0001X, 1223X0400X
UT773140599211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice