Provider Demographics
NPI:1568143030
Name:WAGNER, MARCIE (RDH)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4109
Mailing Address - Country:US
Mailing Address - Phone:415-342-9633
Mailing Address - Fax:
Practice Address - Street 1:155 5TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2919
Practice Address - Country:US
Practice Address - Phone:415-342-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29141124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist