MEDICARE: CORE DENTAL CARE

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1427613074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORE DENTAL CARE

Provider Business Mailing Address
First Line	:	2444 GETZ RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2444 GETZ RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1632
Country	:	US
Telephone Number	:	269-444-4715
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DOREEN AGYEMAN
Credential	:
Telephone Number	:	502-777-7547

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	05/08/2019

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