Provider Demographics
NPI:1437279213
Name:WADE W. WAGNER, D.D.S., CHTD
Entity Type:Organization
Organization Name:WADE W. WAGNER, D.D.S., CHTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-877-2222
Mailing Address - Street 1:4618 MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2956
Mailing Address - Country:US
Mailing Address - Phone:702-877-2222
Mailing Address - Fax:
Practice Address - Street 1:4618 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2956
Practice Address - Country:US
Practice Address - Phone:702-877-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty