Provider Demographics
NPI:1659756658
Name:WAGER, CARLIE (DDS)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:
Last Name:WAGER
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 1:12201 HIGHWAY 92
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7140
Mailing Address - Country:US
Mailing Address - Phone:678-202-4904
Mailing Address - Fax:678-202-4197
Practice Address - Street 1:12201 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7140
Practice Address - Country:US
Practice Address - Phone:678-202-4904
Practice Address - Fax:678-202-4197
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist