Provider Demographics
NPI:1295838878
Name:WAGNER, DONALD EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:EDWARD
Last Name:WAGNER
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 1:147 WILLOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-3050
Mailing Address - Country:US
Mailing Address - Phone:716-691-9195
Mailing Address - Fax:
Practice Address - Street 1:147 WILLOW RIDGE DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-3050
Practice Address - Country:US
Practice Address - Phone:716-691-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24701122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice