Provider Demographics
NPI:1467452037
Name:WAGNER, JOHN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
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 1:7701 LAKEMONT DR NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-5234
Mailing Address - Country:US
Mailing Address - Phone:206-523-7175
Mailing Address - Fax:
Practice Address - Street 1:2211 N 56TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6203
Practice Address - Country:US
Practice Address - Phone:206-632-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice