Provider Demographics
NPI:1508358953
Name:WAGNER, TRAVIS WAYNE (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WAYNE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 VETERANS AVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6444
Mailing Address - Country:US
Mailing Address - Phone:304-255-2121
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6444
Practice Address - Country:US
Practice Address - Phone:304-255-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0426111223G0001X
MD170031223G0001X
WV43401223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice