Provider Demographics
NPI:1821137399
Name:WAGNER, CAMERON J (DMD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:J
Last Name:WAGNER
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 1:2632 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2850
Mailing Address - Country:US
Mailing Address - Phone:773-235-0980
Mailing Address - Fax:773-235-1249
Practice Address - Street 1:2632 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2850
Practice Address - Country:US
Practice Address - Phone:773-235-0980
Practice Address - Fax:773-235-1249
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice