Provider Demographics
NPI:1932332285
Name:STEPHEN A. WAGNER DDS,PC
Entity Type:Organization
Organization Name:STEPHEN A. WAGNER DDS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAXILLOFACIAL PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PC
Authorized Official - Phone:505-232-3588
Mailing Address - Street 1:801 ENCINO PL NE STE A3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2639
Mailing Address - Country:US
Mailing Address - Phone:505-232-3588
Mailing Address - Fax:505-232-3593
Practice Address - Street 1:801 ENCINO PL NE STE A3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2639
Practice Address - Country:US
Practice Address - Phone:505-232-3588
Practice Address - Fax:505-232-3593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1150261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82743Medicaid