MEDICARE: DR. GARY A WULLSCHLAGER 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	1223G0001X	General Practice Dentistry	22693	CA

General Provider Information

NPI Number	:	1447396932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY A WULLSCHLAGER D.D.S

Provider Business Mailing Address
First Line	:	200 S EL MOLINO AVE STE 4
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-2985
Country	:	US
Telephone Number	:	626-796-5591
Fax Number	:	626-796-7769

Provider Business Practice Location Address
First Line	:	200 S EL MOLINO AVE STE 4
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-2985
Country	:	US
Telephone Number	:	626-796-5591
Fax Number	:	626-796-7769

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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