Provider Demographics
NPI:1750638334
Name:GREEN RIVER ORAL SURGERY
Entity Type:Organization
Organization Name:GREEN RIVER ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:570-814-3085
Mailing Address - Street 1:801 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2705
Mailing Address - Country:US
Mailing Address - Phone:270-212-0330
Mailing Address - Fax:270-212-0332
Practice Address - Street 1:801 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2705
Practice Address - Country:US
Practice Address - Phone:270-212-0330
Practice Address - Fax:270-212-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64063514Medicaid
KYU95876Medicare UPIN