Provider Demographics
NPI:1629194964
Name:PETER C. WAGNER, D.M.D., P.S.
Entity Type:Organization
Organization Name:PETER C. WAGNER, D.M.D., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PS
Authorized Official - Phone:360-748-6636
Mailing Address - Street 1:1292 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3645
Mailing Address - Country:US
Mailing Address - Phone:360-748-6636
Mailing Address - Fax:360-748-3176
Practice Address - Street 1:1292 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3645
Practice Address - Country:US
Practice Address - Phone:360-748-6636
Practice Address - Fax:360-748-3176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA69371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5028469Medicaid