MEDICARE: KENNETH WAGSCHAL 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	122300000X	Dentist	035430	NY

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	:	1477530079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WAGSCHAL DDS

Provider Business Mailing Address
First Line	:	1770 E 21ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-1515
Country	:	US
Telephone Number	:	718-710-2247
Fax Number	:

Provider Business Practice Location Address
First Line	:	11818 ROCKAWAY BLVD
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11420-2420
Country	:	US
Telephone Number	:	718-843-5231
Fax Number	:	718-843-1022

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

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	07/08/2007

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