Provider Demographics
NPI:1306231717
Name:NICHOLAS J WAGNER, DDS, LLC
Entity Type:Organization
Organization Name:NICHOLAS J WAGNER, DDS, LLC
Other - Org Name:WARRICK PARK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-897-4889
Mailing Address - Street 1:800 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-8601
Mailing Address - Country:US
Mailing Address - Phone:812-897-4889
Mailing Address - Fax:
Practice Address - Street 1:800 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-8601
Practice Address - Country:US
Practice Address - Phone:812-897-4889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011465A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1023338480Medicaid
IN1588740815Medicaid