Provider Demographics
NPI:1003465964
Name:WAGNER ORTHODONTICS
Entity Type:Organization
Organization Name:WAGNER ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-748-6636
Mailing Address - Street 1:1292 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1292 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3645
Practice Address - Country:US
Practice Address - Phone:360-748-6636
Practice Address - Fax:360-748-3176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETER L. WAGNER, DMD, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty