Provider Demographics
NPI:1154556132
Name:WAGNER, RUDOLPH MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:MICHAEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 TAMPA RD STE I
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3131
Mailing Address - Country:US
Mailing Address - Phone:727-785-8847
Mailing Address - Fax:
Practice Address - Street 1:2595 TAMPA RD STE I
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3131
Practice Address - Country:US
Practice Address - Phone:727-785-8847
Practice Address - Fax:277-785-9372
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL211251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics