Provider Demographics
NPI:1043393341
Name:WAGNER, GEOFFREY W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105
Mailing Address - Country:US
Mailing Address - Phone:207-781-4625
Mailing Address - Fax:207-781-3204
Practice Address - Street 1:251 US ROUTE ONE
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105
Practice Address - Country:US
Practice Address - Phone:207-781-4625
Practice Address - Fax:207-781-3204
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist