Provider Demographics
NPI:1265863112
Name:WAGNER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 OLD PLANTATION WAY
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6375
Mailing Address - Country:US
Mailing Address - Phone:410-653-6886
Mailing Address - Fax:410-653-6986
Practice Address - Street 1:24 OLD PLANTATION WAY
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6375
Practice Address - Country:US
Practice Address - Phone:410-653-6886
Practice Address - Fax:410-653-6986
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist