Provider Demographics
NPI:1952154288
Name:CARROLLTON FAMILY DENTAL
Entity Type:Organization
Organization Name:CARROLLTON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-520-0127
Mailing Address - Street 1:603 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:IL
Mailing Address - Zip Code:62016-1401
Mailing Address - Country:US
Mailing Address - Phone:217-942-5033
Mailing Address - Fax:217-942-9503
Practice Address - Street 1:603 5TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016-1401
Practice Address - Country:US
Practice Address - Phone:217-942-5033
Practice Address - Fax:217-942-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental