Provider Demographics
NPI:1104209790
Name:WAGNER FAMILY DENTAL
Entity type:Organization
Organization Name:WAGNER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-482-4347
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-0712
Mailing Address - Country:US
Mailing Address - Phone:812-482-4347
Mailing Address - Fax:
Practice Address - Street 1:4115 MANNHEIM RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2964
Practice Address - Country:US
Practice Address - Phone:812-482-4347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010568A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty