Provider Demographics
NPI:1821276817
Name:WAGONER FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:WAGONER FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-485-2200
Mailing Address - Street 1:900 E CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4718
Mailing Address - Country:US
Mailing Address - Phone:918-485-2200
Mailing Address - Fax:918-485-8877
Practice Address - Street 1:900 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4718
Practice Address - Country:US
Practice Address - Phone:918-485-2200
Practice Address - Fax:918-485-8877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty