Provider Demographics
NPI:1639534696
Name:EXINDENT
Entity type:Organization
Organization Name:EXINDENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ADAMS
Authorized Official - Last Name:EMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-726-6655
Mailing Address - Street 1:1342 N 650 E
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9848
Mailing Address - Country:US
Mailing Address - Phone:832-726-6655
Mailing Address - Fax:
Practice Address - Street 1:130 CARLANNA LAKE RD
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5669
Practice Address - Country:US
Practice Address - Phone:832-726-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK105109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty