Provider Demographics
NPI:1508013210
Name:WAGNER, JIM A (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7227
Mailing Address - Country:US
Mailing Address - Phone:870-972-5445
Mailing Address - Fax:870-972-0852
Practice Address - Street 1:2605 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-5445
Practice Address - Fax:870-972-0852
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics