Provider Demographics
NPI:1972516615
Name:EDWARD G KROLL,DDS AND ASSOCIATES, PC
Entity Type:Organization
Organization Name:EDWARD G KROLL,DDS AND ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:KROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-891-8088
Mailing Address - Street 1:3704 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1007
Mailing Address - Country:US
Mailing Address - Phone:313-891-8088
Mailing Address - Fax:313-891-8333
Practice Address - Street 1:3704 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1007
Practice Address - Country:US
Practice Address - Phone:313-891-8088
Practice Address - Fax:313-891-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8536261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4015745Medicaid