Provider Demographics
NPI:1699221275
Name:CARROLL, COREY (DMD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
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 1:4323 HILL STREET
Mailing Address - Street 2:
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207
Mailing Address - Country:US
Mailing Address - Phone:803-751-6209
Mailing Address - Fax:
Practice Address - Street 1:4323 HILL STREET
Practice Address - Street 2:
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207
Practice Address - Country:US
Practice Address - Phone:803-751-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9829508-8903122300000X
UT9829508-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist