MEDICARE: CUSTOM DENTAL CARE, P.C.

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	019027406	IL

General Provider Information

NPI Number	:	1932452893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM DENTAL CARE, P.C.

Provider Business Mailing Address
First Line	:	3740 E LAKE CTR STE B
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-5805
Country	:	US
Telephone Number	:	217-214-4545
Fax Number	:	217-214-4546

Provider Business Practice Location Address
First Line	:	3740 E LAKE CTR STE B
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-5805
Country	:	US
Telephone Number	:	217-214-4545
Fax Number	:	217-214-4546

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. DENNIS RYAN WAGNER
Credential	:	D.M.D.
Telephone Number	:	217-430-1429

Provider Enumeration Date	:	10/17/2012
Last Update Date	:	10/17/2012

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