Provider Demographics
NPI:1710050893
Name:WAGNER, RICHARD W JR (DDS MS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 HAMILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104
Mailing Address - Country:US
Mailing Address - Phone:712-258-0501
Mailing Address - Fax:712-258-1461
Practice Address - Street 1:3012 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-258-0501
Practice Address - Fax:712-258-1461
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025343600Medicaid
IA0207233Medicaid
SD7900130Medicaid