Provider Demographics
NPI:1740368935
Name:WAGONER, ROBERT GENE II (DMD MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GENE
Last Name:WAGONER
Suffix:II
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N. ELM STREET
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2705
Mailing Address - Country:US
Mailing Address - Phone:270-212-0330
Mailing Address - Fax:270-212-0332
Practice Address - Street 1:801 N. ELM STREET
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2705
Practice Address - Country:US
Practice Address - Phone:270-212-0330
Practice Address - Fax:270-212-0332
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72981223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000299338OtherANTHEM BLUE CROSS BLUE SH
KY64063514Medicaid
KY60002003Medicaid
KY0218704Medicare PIN
KY60002003Medicaid