Provider Demographics
NPI:1528419074
Name:WAGNER, MARK VINCENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
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 1:2600 VILLAGE PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3285
Mailing Address - Country:US
Mailing Address - Phone:469-444-6500
Mailing Address - Fax:
Practice Address - Street 1:2600 VILLAGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-3285
Practice Address - Country:US
Practice Address - Phone:469-444-6500
Practice Address - Fax:972-317-0777
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34961122300000X
NMDD4556122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist