Provider Demographics
NPI:1326009143
Name:WAGNER, ERIC JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JOHN
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 1:1643 HIGHWAY 65
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:IA
Mailing Address - Zip Code:50441-7444
Mailing Address - Country:US
Mailing Address - Phone:641-456-5472
Mailing Address - Fax:641-456-2404
Practice Address - Street 1:112 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50441-1724
Practice Address - Country:US
Practice Address - Phone:641-456-2625
Practice Address - Fax:641-456-2404
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA069321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0071928Medicaid