Provider Demographics
NPI:1043402894
Name:WAGNER, KUNTZ & GRABOUSKI
Entity Type:Organization
Organization Name:WAGNER, KUNTZ & GRABOUSKI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-258-0501
Mailing Address - Street 1:3021 HAMILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2407
Mailing Address - Country:US
Mailing Address - Phone:712-258-0501
Mailing Address - Fax:712-258-1461
Practice Address - Street 1:3021 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-2407
Practice Address - Country:US
Practice Address - Phone:712-258-0501
Practice Address - Fax:712-258-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025343600Medicaid