MEDICARE: WYDOWN DENTAL GROUP, INC.

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

General Provider Information

NPI Number	:	1568669349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYDOWN DENTAL GROUP, INC.

Provider Business Mailing Address
First Line	:	510 S HANLEY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-2038
Country	:	US
Telephone Number	:	314-721-2346
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 S HANLEY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-2038
Country	:	US
Telephone Number	:	314-721-2346
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAN H ROGERS
Credential	:	DMD
Telephone Number	:	314-721-2346

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	08/22/2020

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