MEDICARE: MRS. AIMEE MEDDERS 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	4770	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4770	OTHER	KY	RDH LICENSE

General Provider Information

NPI Number	:	1538675483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AIMEE MEDDERS RDH

Provider Business Mailing Address
First Line	:	398 192ND ARMOR TANK BATTALION RD RM 226
Second Line	:
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5116
Country	:	US
Telephone Number	:	502-624-6158
Fax Number	:

Provider Business Practice Location Address
First Line	:	968 1ST INFANTRY DIVISION RD BLDG 2724
Second Line	:
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5210
Country	:	US
Telephone Number	:	502-626-8301
Fax Number	:

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

Provider Enumeration Date	:	12/14/2017
Last Update Date	:	12/14/2017

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