Provider Demographics
NPI:1396353025
Name:MARK V WAGNER DMD PLLC
Entity type:Organization
Organization Name:MARK V WAGNER DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:469-444-6500
Mailing Address - Street 1:2600 VILLAGE PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3285
Mailing Address - Country:US
Mailing Address - Phone:469-444-6500
Mailing Address - Fax:972-317-0777
Practice Address - Street 1:2600 VILLAGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-3285
Practice Address - Country:US
Practice Address - Phone:469-444-6500
Practice Address - Fax:972-317-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty