Provider Demographics
NPI:1780638585
Name:WAGNER, ROBERT HAROLD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HAROLD
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 E CARRERA CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2830 CURRY LN
Practice Address - Street 2:SUITE 1
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5882
Practice Address - Country:US
Practice Address - Phone:920-432-7230
Practice Address - Fax:920-432-6948
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice