Provider Demographics
NPI:1750026746
Name:WAGNER, LAUREN ELIZABETH (RDH, PHDHP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RDH, PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:SUMMIT STATION
Mailing Address - State:PA
Mailing Address - Zip Code:17979-0095
Mailing Address - Country:US
Mailing Address - Phone:570-640-1405
Mailing Address - Fax:
Practice Address - Street 1:1110 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19604-1501
Practice Address - Country:US
Practice Address - Phone:610-988-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist