Provider Demographics
NPI:1942509179
Name:SEDALIA DENTAL - DR. KATHERINE CARROLL, DMD, INC.
Entity Type:Organization
Organization Name:SEDALIA DENTAL - DR. KATHERINE CARROLL, DMD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:614-836-2222
Mailing Address - Street 1:5327 HENDRON RD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-1055
Mailing Address - Country:US
Mailing Address - Phone:614-836-2222
Mailing Address - Fax:614-836-0659
Practice Address - Street 1:5327 HENDRON RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1055
Practice Address - Country:US
Practice Address - Phone:614-836-2222
Practice Address - Fax:614-836-0659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300229481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2981993Medicaid
OH3060431Medicaid