MEDICARE: LEE CARRIKER RDH

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	124Q00000X	Dental Hygienist	H2997	MN

General Provider Information

NPI Number	:	1376920447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE CARRIKER RDH

Provider Business Mailing Address
First Line	:	PO BOX 497
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0497
Country	:	US
Telephone Number	:	218-679-0119
Fax Number	:

Provider Business Practice Location Address
First Line	:	24760 HOSPITAL RD
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0497
Country	:	US
Telephone Number	:	218-679-0119
Fax Number	:

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

Provider Enumeration Date	:	04/28/2015
Last Update Date	:	04/28/2015

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