Provider Demographics
NPI:1952570103
Name:CAROLINA DENTAL GROUP
Entity Type:Organization
Organization Name:CAROLINA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-288-6404
Mailing Address - Street 1:132 MILESTONE WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5065
Mailing Address - Country:US
Mailing Address - Phone:864-288-6404
Mailing Address - Fax:864-288-2515
Practice Address - Street 1:132 MILESTONE WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5065
Practice Address - Country:US
Practice Address - Phone:864-288-6404
Practice Address - Fax:864-288-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty