Provider Demographics
NPI:1508897406
Name:WAGNER KETHCART, STEPHANIE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:WAGNER KETHCART
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 1:1277 E MISSOURI AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2916
Mailing Address - Country:US
Mailing Address - Phone:602-615-8516
Mailing Address - Fax:602-883-7252
Practice Address - Street 1:1277 E MISSOURI AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2916
Practice Address - Country:US
Practice Address - Phone:602-812-4326
Practice Address - Fax:602-883-7252
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD66951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice