MEDICARE: DR. ELYSE ANNE WAGNER 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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223P0700X	Prosthodontics	DN1858351	MA

General Provider Information

NPI Number	:	1023509007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELYSE ANNE WAGNER DMD

Provider Business Mailing Address
First Line	:	93 UNION ST STE 402
Second Line	:
City	:	NEWTON CENTRE
State	:	MA
Zip	:	02459-2241
Country	:	US
Telephone Number	:	617-965-0060
Fax Number	:

Provider Business Practice Location Address
First Line	:	93 UNION ST STE 402
Second Line	:
City	:	NEWTON CENTRE
State	:	MA
Zip	:	02459-2241
Country	:	US
Telephone Number	:	179-650-0606
Fax Number	:

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

Provider Enumeration Date	:	05/24/2018
Last Update Date	:	05/07/2021

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