MEDICARE: YEN WAGNER DDS LLC

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	261QD0000X	Dental Clinic/Center	12010286A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316277411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YEN WAGNER DDS LLC

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	:	OWNER
Name	:	YEN WAGNER
Credential	:	DDS
Telephone Number	:	317-925-5811

Provider Enumeration Date	:	01/12/2010
Last Update Date	:	01/12/2010

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