SAM ADAM CARROLL Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****40

License Status

NOT RENEWED

Business

First Name

SAM

Middle

ADAM

Last Name

CARROLL

Business Name

SAM ADAM CARROLL

Original Issue Date

06/09/2009

Effective Date

06/09/2009

Expiration Date

09/30/2012

City

PEORIA

State

Zip

61614

County

PEORIA

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/14/2012