Provider Demographics
NPI:1417087982
Name:WAGNER, SUSAN ELAINE (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8849 SHELBY ST
Mailing Address - Street 2:A-2
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7508
Mailing Address - Country:US
Mailing Address - Phone:317-881-4000
Mailing Address - Fax:317-888-1762
Practice Address - Street 1:8849 SHELBY ST
Practice Address - Street 2:A-2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7508
Practice Address - Country:US
Practice Address - Phone:317-881-4000
Practice Address - Fax:317-888-1762
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120087391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice