Provider Demographics
NPI:1255643359
Name:WAGSTAFF, CARSON B (DMD)
Entity type:Individual
Prefix:DR
First Name:CARSON
Middle Name:B
Last Name:WAGSTAFF
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 1:1225 W MOODIE DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-6000
Mailing Address - Country:US
Mailing Address - Phone:801-979-2035
Mailing Address - Fax:
Practice Address - Street 1:13435 N LON ADAMS RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653
Practice Address - Country:US
Practice Address - Phone:520-989-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist