Provider Demographics
NPI:1225019201
Name:WAGONER, BRADLEY DUANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DUANE
Last Name:WAGONER
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 1:3400 CROWN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-1446
Mailing Address - Country:US
Mailing Address - Phone:319-373-0322
Mailing Address - Fax:
Practice Address - Street 1:955 31ST ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-3788
Practice Address - Country:US
Practice Address - Phone:319-377-4867
Practice Address - Fax:319-377-4383
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA68941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0207225Medicaid