Provider Demographics
NPI:1578761631
Name:WAGNER, MARY JUNE ASENATHE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY JUNE
Middle Name:ASENATHE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARYJUNE
Other - Middle Name:ASENATHE
Other - Last Name:DENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1795 EL CAMINO REAL #100
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306
Mailing Address - Country:US
Mailing Address - Phone:650-328-1223
Mailing Address - Fax:650-327-8903
Practice Address - Street 1:1795 EL CAMINO REAL #100
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306
Practice Address - Country:US
Practice Address - Phone:650-328-1223
Practice Address - Fax:650-327-8903
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA467791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice