MEDICARE: KINNARA VASAMSETTI EMMONS DMD

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	1223G0001X	General Practice Dentistry	9420	SC

General Provider Information

NPI Number	:	1922650647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KINNARA VASAMSETTI EMMONS DMD

Provider Business Mailing Address
First Line	:	2754 MAYBANK HWY
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-559-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	2754 MAYBANK HWY
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-559-5555
Fax Number	:

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

Provider Enumeration Date	:	07/12/2019
Last Update Date	:	12/01/2020

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