Provider Demographics
NPI:1215141890
Name:WAGMAN, JEFFREY DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:WAGMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 W BRADDOCK RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1915
Mailing Address - Country:US
Mailing Address - Phone:703-379-6187
Mailing Address - Fax:703-379-8656
Practice Address - Street 1:3541 W BRADDOCK RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1915
Practice Address - Country:US
Practice Address - Phone:703-379-6187
Practice Address - Fax:703-379-8656
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010082711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice