Provider Demographics
NPI:1093020372
Name:WAGNER, REBECCA L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:W
Other - Last Name:BYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:129 CHAMBERS HILL DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-7302
Mailing Address - Country:US
Mailing Address - Phone:717-263-0606
Mailing Address - Fax:
Practice Address - Street 1:129 CHAMBERS HILL DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-7302
Practice Address - Country:US
Practice Address - Phone:717-263-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD104861223P0300X
PADS039409122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics