MEDICARE: DR. PHILIP M WANEZEK 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	2513-015	WI

General Provider Information

NPI Number	:	1649673435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP M WANEZEK D.D.S

Provider Business Mailing Address
First Line	:	PO BOX 15
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-0015
Country	:	US
Telephone Number	:	262-642-5881
Fax Number	:	262-642-7252

Provider Business Practice Location Address
First Line	:	3278 MAIN ST
Second Line	:	SUITE A
City	:	EAST TROY
State	:	WI
Zip	:	53120-1152
Country	:	US
Telephone Number	:	262-642-5881
Fax Number	:	262-642-7252

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

Provider Enumeration Date	:	10/07/2014
Last Update Date	:	10/07/2014

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