Provider Demographics
NPI:1629014485
Name:WAGNER, RICHARD BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRUCE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 DENTAL SCIENCE S
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1001
Mailing Address - Country:US
Mailing Address - Phone:319-384-1139
Mailing Address - Fax:319-384-1775
Practice Address - Street 1:346 DENTAL SCIENCE S
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1001
Practice Address - Country:US
Practice Address - Phone:319-335-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA059781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice