MEDICARE: WOLF D BUESCHGEN DMD

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	3961	SC

General Provider Information

NPI Number	:	1588699029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WOLF D BUESCHGEN DMD

Provider Business Mailing Address
First Line	:	2060 CHARLIE HALL BLVD
Second Line	:	SUITE 5A
City	:	CHARLESTON
State	:	SC
Zip	:	29414-5830
Country	:	US
Telephone Number	:	843-763-5665
Fax Number	:	843-766-7376

Provider Business Practice Location Address
First Line	:	2060 CHARLIE HALL BLVD
Second Line	:	SUITE 5A
City	:	CHARLESTON
State	:	SC
Zip	:	29414-5830
Country	:	US
Telephone Number	:	843-763-5665
Fax Number	:	843-766-7376

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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