Provider Demographics
NPI:1598731408
Name:WAGONER, CAROLYN BEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:BEAN
Last Name:WAGONER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 EARLYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EARLYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22936-9563
Mailing Address - Country:US
Mailing Address - Phone:434-963-7640
Mailing Address - Fax:
Practice Address - Street 1:259 HYDRAULIC RIDGE RD
Practice Address - Street 2:SUITE # 101
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8128
Practice Address - Country:US
Practice Address - Phone:434-293-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010083121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice