Provider Demographics
NPI:1952855470
Name:DAVID A WAGNER DDS
Entity Type:Organization
Organization Name:DAVID A WAGNER DDS
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:ALAN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-797-5161
Mailing Address - Street 1:3023 EASTLAND BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-4106
Mailing Address - Country:US
Mailing Address - Phone:727-797-5161
Mailing Address - Fax:727-797-5121
Practice Address - Street 1:3023 EASTLAND BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-4106
Practice Address - Country:US
Practice Address - Phone:727-797-5161
Practice Address - Fax:727-797-5121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13625122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty