MEDICARE: DR. THOMAS GENE MAGNUSON 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	122300000X	Dentist	12010309A	IN

General Provider Information

NPI Number	:	1265693634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS GENE MAGNUSON D.D.S.

Provider Business Mailing Address
First Line	:	4550 S IRONWOOD DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-9595
Country	:	US
Telephone Number	:	574-299-0484
Fax Number	:	574-299-0447

Provider Business Practice Location Address
First Line	:	4550 S IRONWOOD DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-9595
Country	:	US
Telephone Number	:	574-299-0484
Fax Number	:	574-299-0447

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

Provider Enumeration Date	:	06/18/2008
Last Update Date	:	06/18/2008

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