MEDICARE: EXINDENT

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	122300000X	Dentist	105109	AK

General Provider Information

NPI Number	:	1639534696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXINDENT

Provider Business Mailing Address
First Line	:	1342 N 650 E
Second Line	:
City	:	TOOELE
State	:	UT
Zip	:	84074-9848
Country	:	US
Telephone Number	:	832-726-6655
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 CARLANNA LAKE RD
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-5669
Country	:	US
Telephone Number	:	832-726-6655
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. PETER ADAMS EMMONS
Credential	:	DDS
Telephone Number	:	832-726-6655

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	12/17/2015

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Directions to “EXINDENT ” Practice Location

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