Provider Demographics
NPI:1942450937
Name:DAVID E WAGNER DMD LLC
Entity Type:Organization
Organization Name:DAVID E WAGNER DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-731-2273
Mailing Address - Street 1:5992 HOWDERSHELL RD
Mailing Address - Street 2:STE 206
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-4107
Mailing Address - Country:US
Mailing Address - Phone:314-731-2273
Mailing Address - Fax:314-731-2096
Practice Address - Street 1:5992 HOWDERSHELL RD
Practice Address - Street 2:STE 206
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-4107
Practice Address - Country:US
Practice Address - Phone:314-731-2273
Practice Address - Fax:314-731-2096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty