Provider Demographics
NPI:1427147792
Name:WAGNER, DENNIS S (DMD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:S
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 1:2103 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3912
Mailing Address - Country:US
Mailing Address - Phone:503-842-5320
Mailing Address - Fax:503-842-5320
Practice Address - Street 1:2103 10TH ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3912
Practice Address - Country:US
Practice Address - Phone:503-842-5320
Practice Address - Fax:503-842-5320
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4590122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist