MEDICARE: WAYNE YOUTH DENTISTRY, 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	1223G0001X	General Practice Dentistry

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356399182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYNE YOUTH DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	16 ARCADE UNIT 198747
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37219-1994
Country	:	US
Telephone Number	:	615-750-0343
Fax Number	:	615-986-1705

Provider Business Practice Location Address
First Line	:	7524 S ANTHONY BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2517
Country	:	US
Telephone Number	:	260-441-8500
Fax Number	:	260-441-0887

Authorized Official
Title or Position	:	MANAGER, LICENSING & CREDENTIALING
Name	:	MRS. JENELL STUMP
Credential	:
Telephone Number	:	615-750-0343

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/09/2014

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