Provider Demographics
NPI:1295783256
Name:WAGNER, JAMES M (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 REGATTA DR
Mailing Address - Street 2:110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-6891
Mailing Address - Country:US
Mailing Address - Phone:702-648-1200
Mailing Address - Fax:
Practice Address - Street 1:2620 REGATTA DR
Practice Address - Street 2:110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-6891
Practice Address - Country:US
Practice Address - Phone:702-648-1200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV30671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice