Provider Demographics
NPI:1689053597
Name:KLW DENTISTRY
Entity Type:Organization
Organization Name:KLW DENTISTRY
Other - Org Name:TAYLOR WAGNER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-972-6985
Mailing Address - Street 1:2000 FIELDERS RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-1937
Mailing Address - Country:US
Mailing Address - Phone:870-972-6985
Mailing Address - Fax:870-972-5536
Practice Address - Street 1:2000 FIELDERS RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-1937
Practice Address - Country:US
Practice Address - Phone:870-972-6985
Practice Address - Fax:870-972-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty