Provider Demographics
NPI:1154338101
Name:WAGNER, JON DAGLEY (MD DDS)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:DAGLEY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 COORS BYP NW
Mailing Address - Street 2:SUITE G-218
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4040
Mailing Address - Country:US
Mailing Address - Phone:505-242-4867
Mailing Address - Fax:
Practice Address - Street 1:10000 COORS BYP NW
Practice Address - Street 2:SUITE G-218
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4040
Practice Address - Country:US
Practice Address - Phone:505-242-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX95-367208200000X
NMDD38421223S0112X
TX286341223S0112X
NY055441-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery