Provider Demographics
NPI:1912017302
Name:FARIA, WAGNER DE LUCA (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAGNER
Middle Name:DE LUCA
Last Name:FARIA
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 1:143 N PLYMOUTH WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4173
Mailing Address - Country:US
Mailing Address - Phone:909-533-4139
Mailing Address - Fax:
Practice Address - Street 1:143 N PLYMOUTH WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4173
Practice Address - Country:US
Practice Address - Phone:909-533-4139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA441691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice