Provider Demographics
NPI:1891085569
Name:MELINDA L. WAGNER DMD LLC
Entity type:Organization
Organization Name:MELINDA L. WAGNER DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-747-2022
Mailing Address - Street 1:191 BROAD ST.
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-747-2022
Mailing Address - Fax:732-747-5524
Practice Address - Street 1:191 BROAD ST.
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701
Practice Address - Country:US
Practice Address - Phone:732-747-2022
Practice Address - Fax:732-747-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ141421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty