Provider Demographics
NPI:1336131267
Name:WAGNER, STEPHEN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
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 1:801 ENCINO PL NE
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2612
Mailing Address - Country:US
Mailing Address - Phone:505-232-3588
Mailing Address - Fax:505-232-3593
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:SUITE A-3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2612
Practice Address - Country:US
Practice Address - Phone:505-232-3588
Practice Address - Fax:505-232-3593
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11501223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82743Medicaid