Provider Demographics
NPI:1851744478
Name:MICHAEL J. WAGNER
Entity Type:Organization
Organization Name:MICHAEL J. WAGNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PS
Authorized Official - Phone:425-483-2600
Mailing Address - Street 1:13515 NE 175TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-8566
Mailing Address - Country:US
Mailing Address - Phone:425-483-2600
Mailing Address - Fax:425-483-0840
Practice Address - Street 1:13515 NE 175TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8566
Practice Address - Country:US
Practice Address - Phone:425-483-2600
Practice Address - Fax:425-483-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6026809251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty