Provider Demographics
NPI:1235676008
Name:WAGNER, PETER LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LOUIS
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 1:705 CRAB ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:360-269-6993
Mailing Address - Fax:
Practice Address - Street 1:1292 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3645
Practice Address - Country:US
Practice Address - Phone:360-748-6636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10580122300000X
WADE607327471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentist