Provider Demographics
NPI:1760919849
Name:WEGNER, NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:WEGNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BEN CASEY DR
Mailing Address - Street 2:STE 115
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8557
Mailing Address - Country:US
Mailing Address - Phone:803-548-9910
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD # UH-3143
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-274-5315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC98321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty