Provider Demographics
NPI:1003876988
Name:WAGNER, WAYNE F (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:F
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 N NORTHWEST HWY
Mailing Address - Street 2:#300
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1469
Mailing Address - Country:US
Mailing Address - Phone:847-390-8200
Mailing Address - Fax:847-390-0479
Practice Address - Street 1:1580 N NORTHWEST HWY
Practice Address - Street 2:#300
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1469
Practice Address - Country:US
Practice Address - Phone:847-390-8200
Practice Address - Fax:847-390-0479
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T37299Medicare UPIN
617180Medicare ID - Type Unspecified