Provider Demographics
NPI:1528157401
Name:WAGNER, JOSEPH LAWRENCE III (DMD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LAWRENCE
Last Name:WAGNER
Suffix:III
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 1:4882 BROWNSBORO RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2342
Mailing Address - Country:US
Mailing Address - Phone:502-896-4374
Mailing Address - Fax:502-896-4350
Practice Address - Street 1:4882 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2342
Practice Address - Country:US
Practice Address - Phone:502-896-4374
Practice Address - Fax:502-896-4350
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY67571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice