Provider Demographics
NPI:1932318995
Name:DRS. WAGONER & WAGONER, PC
Entity Type:Organization
Organization Name:DRS. WAGONER & WAGONER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MAGD
Authorized Official - Phone:574-967-4434
Mailing Address - Street 1:17 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IN
Mailing Address - Zip Code:46929-1335
Mailing Address - Country:US
Mailing Address - Phone:574-967-4434
Mailing Address - Fax:574-967-4426
Practice Address - Street 1:17 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IN
Practice Address - Zip Code:46929-1335
Practice Address - Country:US
Practice Address - Phone:574-967-4434
Practice Address - Fax:574-967-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120073941223G0001X
IN120093761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty