Healthcare Provider Details

I. General information

NPI: 1649622820
Provider Name (Legal Business Name): BRANDON YEAGER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 VAUGHN RD
WOOD RIVER IL
62095-2511
US

IV. Provider business mailing address

1915 VAUGHN RD
WOOD RIVER IL
62095-2511
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-2007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030718
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: