MEDICARE: DR. EMMA J KOUKOL DDS

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	1223E0200X	Endodontics	13959	MA

General Provider Information

NPI Number	:	1114148475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMMA J KOUKOL DDS

Provider Business Mailing Address
First Line	:	411 MASSACHUSETTS AVE
Second Line	:	SUITE 203
City	:	ACTON
State	:	MA
Zip	:	01720-3739
Country	:	US
Telephone Number	:	978-263-1154
Fax Number	:	978-263-1155

Provider Business Practice Location Address
First Line	:	411 MASSACHUSETTS AVE
Second Line	:	SUITE 203
City	:	ACTON
State	:	MA
Zip	:	01720-3739
Country	:	US
Telephone Number	:	978-263-1154
Fax Number	:	978-263-1155

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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