Provider Demographics
NPI:1255337788
Name:WAGNER, CHING-SHU (DDS)
Entity type:Individual
Prefix:DR
First Name:CHING-SHU
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-3529
Mailing Address - Country:US
Mailing Address - Phone:765-644-8828
Mailing Address - Fax:765-642-8886
Practice Address - Street 1:2126 E 5TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3529
Practice Address - Country:US
Practice Address - Phone:765-644-8828
Practice Address - Fax:765-642-8886
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008738A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist