MEDICARE: JESSICA YEAGER 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	DT-2402	HI
2	122300000X	Dentist	27402	TX

General Provider Information

NPI Number	:	1689992992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA YEAGER DDS

Provider Business Mailing Address
First Line	:	7630 N BEACH ST STE 130
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-3018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7630 N BEACH ST STE 130
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-3018
Country	:	US
Telephone Number	:	817-485-7775
Fax Number	:

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

Provider Enumeration Date	:	05/11/2010
Last Update Date	:	09/26/2011

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