MEDICARE: KERRI LYNN MACK 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	DH24313	FL

General Provider Information

NPI Number	:	1538746458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRI LYNN MACK RDH

Provider Business Mailing Address
First Line	:	1534 PATRIOT DR
Second Line	:
City	:	JUNCTION CITY
State	:	KS
Zip	:	66441-1984
Country	:	US
Telephone Number	:	850-377-6369
Fax Number	:

Provider Business Practice Location Address
First Line	:	4010 1ST DIVISION RD
Second Line	:
City	:	FT RILEY
State	:	KS
Zip	:	66442
Country	:	US
Telephone Number	:	785-239-4174
Fax Number	:

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

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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