MEDICARE: RSS LAWRENCE EMMOTT LLC

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	DO2275	AZ

General Provider Information

NPI Number	:	1275043473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RSS LAWRENCE EMMOTT LLC

Provider Business Mailing Address
First Line	:	1050 TEXAN TRL STE 300
Second Line	:
City	:	GRAPEVINE
State	:	TX
Zip	:	76051-3759
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 E MEDLOCK DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4127
Country	:	US
Telephone Number	:	866-500-4985
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAWRENCE EMMOTT
Credential	:	DDS
Telephone Number	:	866-500-4985

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	10/03/2017

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