Provider Demographics
NPI:1083794549
Name:WAGNER, LLOYD WILLIAM III (DMD)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:WILLIAM
Last Name:WAGNER
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 MCFARLAND CIRCLE NORTH
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406
Mailing Address - Country:US
Mailing Address - Phone:205-345-7755
Mailing Address - Fax:205-343-9075
Practice Address - Street 1:217 MCFARLAND CIRCLE NORTH
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406
Practice Address - Country:US
Practice Address - Phone:205-345-7755
Practice Address - Fax:205-343-9075
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5177122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51526480OtherBLUE CROSS BLUE SHIELD