=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023509007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELYSE ANNE WAGNER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2018
-----------------------------------------------------
Last Update Date | 05/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 93 UNION ST STE 402
-----------------------------------------------------
City | NEWTON CENTRE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02459-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 179-650-0606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 93 UNION ST STE 402
-----------------------------------------------------
City | NEWTON CENTRE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02459-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-965-0060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DN1858351
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------