Provider Demographics
NPI:1164599700
Name:WAGNER, ROBERT FREDERICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:FREDERICK
Last Name:WAGNER
Suffix:
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 1:2803 NE EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3246
Mailing Address - Country:US
Mailing Address - Phone:503-239-5115
Mailing Address - Fax:503-231-6480
Practice Address - Street 1:2803 NE EVERETT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3246
Practice Address - Country:US
Practice Address - Phone:503-239-5115
Practice Address - Fax:503-231-6480
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD75491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice