MEDICARE: ELKINS DENTISTRY, PLLC

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	D-3922	ID

General Provider Information

NPI Number	:	1699051250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELKINS DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	1110 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-369-4532
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLARK ELKINS
Credential	:	D.M.D.
Telephone Number	:	208-369-4532

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	03/28/2012

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