MEDICARE: DR. BRANDON YEAGER 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	122300000X	Dentist	019.030718	IL

General Provider Information

NPI Number	:	1649622820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDON YEAGER DMD

Provider Business Mailing Address
First Line	:	1915 VAUGHN RD
Second Line	:
City	:	WOOD RIVER
State	:	IL
Zip	:	62095-2511
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1915 VAUGHN RD
Second Line	:
City	:	WOOD RIVER
State	:	IL
Zip	:	62095-2511
Country	:	US
Telephone Number	:	618-259-2007
Fax Number	:

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

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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