Provider Demographics
NPI:1093044125
Name:WAGMAN, DALE EILLOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:EILLOTT
Last Name:WAGMAN
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 1:2972 WEATHERLY RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-8880
Mailing Address - Country:US
Mailing Address - Phone:517-546-6254
Mailing Address - Fax:
Practice Address - Street 1:2972 WEATHERLY RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8880
Practice Address - Country:US
Practice Address - Phone:517-546-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-20
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist