Provider Demographics
NPI:1215030184
Name:WAGERS, JILL SHELTON (DMD)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:SHELTON
Last Name:WAGERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 EMERALD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8600
Mailing Address - Country:US
Mailing Address - Phone:208-376-7740
Mailing Address - Fax:208-376-0468
Practice Address - Street 1:7235 EMERALD ST
Practice Address - Street 2:SUITE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8600
Practice Address - Country:US
Practice Address - Phone:208-376-7740
Practice Address - Fax:208-376-0468
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6G595OtherBLUE CROSS