MEDICARE: ARJAY J ETZELMILLER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5962	NE

General Provider Information

NPI Number	:	1295904530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARJAY J ETZELMILLER D.D.S.

Provider Business Mailing Address
First Line	:	3200 PINE LAKE RD
Second Line	:	SUITE C
City	:	LINCOLN
State	:	NE
Zip	:	68516
Country	:	US
Telephone Number	:	402-420-2266
Fax Number	:	402-420-2310

Provider Business Practice Location Address
First Line	:	3200 PINE LAKE RD
Second Line	:	SUITE C
City	:	LINCOLN
State	:	NE
Zip	:	68516-6035
Country	:	US
Telephone Number	:	402-420-2266
Fax Number	:	402-420-2310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2008
Last Update Date	:	02/20/2008

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