Provider Demographics
NPI:1275682254
Name:WAGNER, BARBRA J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BARBRA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-1100
Mailing Address - Country:US
Mailing Address - Phone:570-966-8800
Mailing Address - Fax:570-966-4866
Practice Address - Street 1:1100 CHESTNUT ST.
Practice Address - Street 2:
Practice Address - City:MIFFLINBURG
Practice Address - State:PA
Practice Address - Zip Code:17844
Practice Address - Country:US
Practice Address - Phone:570-966-8800
Practice Address - Fax:570-966-4866
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028989L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice