MEDICARE: DR. YEN T WAGNER DDS

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	53337	CA
2	122300000X	Dentist	12010286A	IN

General Provider Information

NPI Number	:	1285613000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YEN T WAGNER DDS

Provider Business Mailing Address
First Line	:	3965 N MERIDIAN ST APT 1C
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4035
Country	:	US
Telephone Number	:	317-925-5811
Fax Number	:

Provider Business Practice Location Address
First Line	:	3965 N MERIDIAN ST APT 1C
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4035
Country	:	US
Telephone Number	:	317-925-5811
Fax Number	:

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	07/30/2009

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