Provider Demographics
NPI:1003216698
Name:WAGNER DENTAL LLC
Entity Type:Organization
Organization Name:WAGNER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-878-5599
Mailing Address - Street 1:2045 VILLAGE CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-6251
Mailing Address - Country:US
Mailing Address - Phone:702-878-5599
Mailing Address - Fax:702-878-0173
Practice Address - Street 1:2045 VILLAGE CENTER CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-6251
Practice Address - Country:US
Practice Address - Phone:702-878-5599
Practice Address - Fax:702-878-0173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty