MEDICARE: DR. WENDELL ALAN EDGIN DDS

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12355	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619977493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WENDELL ALAN EDGIN DDS

Provider Business Mailing Address
First Line	:	4499 MEDICAL DR
Second Line	:	SUITE 190
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3735
Country	:	US
Telephone Number	:	210-614-3916
Fax Number	:	210-614-3918

Provider Business Practice Location Address
First Line	:	4499 MEDICAL DR
Second Line	:	SUITE 190
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3735
Country	:	US
Telephone Number	:	210-614-3916
Fax Number	:	210-614-3918

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

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	02/28/2008

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