Provider Demographics
NPI:1790203941
Name:CARROLL, LUCINDA ROSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUCINDA
Middle Name:ROSE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11735 SUNBURST ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2244
Mailing Address - Country:US
Mailing Address - Phone:402-280-4569
Mailing Address - Fax:
Practice Address - Street 1:2500 CALIFORNIA PLAZA
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68178-0212
Practice Address - Country:US
Practice Address - Phone:402-280-4569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice