Provider Demographics
NPI:1558988816
Name:WAGNER, ROBERT JACOB III (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JACOB
Last Name:WAGNER
Suffix:III
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 1:328 COMMERCIAL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3766
Mailing Address - Country:US
Mailing Address - Phone:909-799-9988
Mailing Address - Fax:
Practice Address - Street 1:328 COMMERCIAL RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3766
Practice Address - Country:US
Practice Address - Phone:909-799-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100072251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice