MEDICARE: DR. WENDY L KOURY 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	1223G0001X	General Practice Dentistry	D10401	MN

General Provider Information

NPI Number	:	1578551503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WENDY L KOURY DDS

Provider Business Mailing Address
First Line	:	2418 ENTERPRISE DR
Second Line	:	SUITE B
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1143
Country	:	US
Telephone Number	:	651-452-2116
Fax Number	:	651-452-2695

Provider Business Practice Location Address
First Line	:	2418 ENTERPRISE DR
Second Line	:	SUITE B
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1143
Country	:	US
Telephone Number	:	651-452-2116
Fax Number	:	651-452-2695

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

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	07/08/2007

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