Provider Demographics
NPI:1558532333
Name:WAGNER, DAVID ALAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALAN
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 1:3023 EASTLAND BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-4106
Mailing Address - Country:US
Mailing Address - Phone:727-797-5161
Mailing Address - Fax:727-797-5121
Practice Address - Street 1:3023 EASTLAND BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-4106
Practice Address - Country:US
Practice Address - Phone:727-797-5161
Practice Address - Fax:727-797-5121
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist