MEDICARE: HANNAH MICHELE WAGNER 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	122300000X	Dentist	DS045529	PA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1871348144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNAH MICHELE WAGNER DMD

Provider Business Mailing Address
First Line	:	1420 LOCUST ST APT 14Q
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4203
Country	:	US
Telephone Number	:	215-630-0229
Fax Number	:

Provider Business Practice Location Address
First Line	:	5629 VINE ST STE C9
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139
Country	:	US
Telephone Number	:	215-383-1376
Fax Number	:

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

Provider Enumeration Date	:	04/20/2024
Last Update Date	:	03/02/2026

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