MEDICARE: DR. TODD RICHARD WELLENSIEK D.D.S

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	4667	NE

General Provider Information

NPI Number	:	1780673350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD RICHARD WELLENSIEK D.D.S

Provider Business Mailing Address
First Line	:	684 N 5TH ST
Second Line	:
City	:	TECUMSEH
State	:	NE
Zip	:	68450-2055
Country	:	US
Telephone Number	:	402-335-3791
Fax Number	:	402-335-3891

Provider Business Practice Location Address
First Line	:	684 N 5TH ST
Second Line	:
City	:	TECUMSEH
State	:	NE
Zip	:	68450-2055
Country	:	US
Telephone Number	:	402-335-3791
Fax Number	:	402-335-3891

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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