MEDICARE: AEGIS DENTAL GROUP FORT WAYNE, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1992506513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEGIS DENTAL GROUP FORT WAYNE, LLC

Provider Business Mailing Address
First Line	:	4975 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	574-875-7711
Fax Number	:

Provider Business Practice Location Address
First Line	:	4975 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	574-875-7711
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	CYNTHIA NEUENSCHWANDER
Credential	:
Telephone Number	:	574-875-7711

Provider Enumeration Date	:	03/20/2025
Last Update Date	:	03/20/2025

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