Provider Demographics
NPI:1932499035
Name:WAGNER FAMILY DENTISTRY
Entity Type:Organization
Organization Name:WAGNER FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-239-5115
Mailing Address - Street 1:2803 NE EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3246
Mailing Address - Country:US
Mailing Address - Phone:503-239-5115
Mailing Address - Fax:503-231-6480
Practice Address - Street 1:2803 NE EVERETT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3246
Practice Address - Country:US
Practice Address - Phone:503-239-5115
Practice Address - Fax:503-231-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD75491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6516320001Medicare NSC