Provider Demographics
NPI:1568522910
Name:F JOHN WAGNER
Entity Type:Organization
Organization Name:F JOHN WAGNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-544-2096
Mailing Address - Street 1:7791 MYSTIC LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48632-9743
Mailing Address - Country:US
Mailing Address - Phone:989-544-2096
Mailing Address - Fax:
Practice Address - Street 1:7791 MYSTIC LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKE
Practice Address - State:MI
Practice Address - Zip Code:48632-9743
Practice Address - Country:US
Practice Address - Phone:989-544-2096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10266261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental