Provider Demographics
NPI:1932530151
Name:CARSON B. WAGSTAFF, DMD, PLC
Entity type:Organization
Organization Name:CARSON B. WAGSTAFF, DMD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARSON
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAGSTAFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-979-2035
Mailing Address - Street 1:13435 N LON ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653
Mailing Address - Country:US
Mailing Address - Phone:801-979-2035
Mailing Address - Fax:
Practice Address - Street 1:13435 N LON ADAMS RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653
Practice Address - Country:US
Practice Address - Phone:801-979-2035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental