Provider Demographics
NPI:1790893410
Name:WAGNER, BRIAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
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:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-0143
Mailing Address - Country:US
Mailing Address - Phone:812-683-2431
Mailing Address - Fax:812-683-4603
Practice Address - Street 1:7120 S US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-9319
Practice Address - Country:US
Practice Address - Phone:812-683-2431
Practice Address - Fax:812-683-4603
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010568A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200445380AMedicaid
IN612224OtherUNITED CONCORDIA
IN200130OtherCHILDREN'S SPECIAL HEALTH