Provider Demographics
NPI:1639466865
Name:WAGNER, DAVID J (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
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 1:2730 WILSHIRE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4744
Mailing Address - Country:US
Mailing Address - Phone:310-828-1513
Mailing Address - Fax:
Practice Address - Street 1:2730 WILSHIRE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4744
Practice Address - Country:US
Practice Address - Phone:310-828-1513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA604681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice