Provider Demographics
NPI:1023562907
Name:WAGNER, CHRISTOPHER
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4808 37TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3017
Mailing Address - Country:US
Mailing Address - Phone:360-624-3235
Mailing Address - Fax:
Practice Address - Street 1:4700 42ND AVE SW
Practice Address - Street 2:SUITE 460
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4591
Practice Address - Country:US
Practice Address - Phone:206-767-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA606757221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice