Provider Demographics
NPI:1316277411
Name:YEN WAGNER DDS LLC
Entity type:Organization
Organization Name:YEN WAGNER DDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-925-5811
Mailing Address - Street 1:3965 N MERIDIAN ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4035
Mailing Address - Country:US
Mailing Address - Phone:317-925-5811
Mailing Address - Fax:
Practice Address - Street 1:3965 N MERIDIAN ST APT 1C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4035
Practice Address - Country:US
Practice Address - Phone:317-925-5811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010286A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200919550Medicaid