Provider Demographics
NPI:1205994878
Name:WAGNER, ROBERT L (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 ROUTE 111
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3700
Mailing Address - Country:US
Mailing Address - Phone:631-265-2990
Mailing Address - Fax:631-265-2994
Practice Address - Street 1:50 ROUTE 111
Practice Address - Street 2:SUITE 301
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3700
Practice Address - Country:US
Practice Address - Phone:631-265-2990
Practice Address - Fax:631-265-2994
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0033796122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist