Provider Demographics
NPI:1598053605
Name:WAGSTAFF, ROSS O
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:O
Last Name:WAGSTAFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-1647
Mailing Address - Country:US
Mailing Address - Phone:937-382-2041
Mailing Address - Fax:
Practice Address - Street 1:150 N SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-1647
Practice Address - Country:US
Practice Address - Phone:937-382-2041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023499122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30-023499OtherDENTAL LICENSE