Provider Demographics
NPI:1770700957
Name:WAGNER, RICHARD M (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
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 1:1925 SOUTH GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4654
Mailing Address - Country:US
Mailing Address - Phone:262-634-4646
Mailing Address - Fax:262-634-4694
Practice Address - Street 1:1925 SOUTH GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4654
Practice Address - Country:US
Practice Address - Phone:262-634-4646
Practice Address - Fax:262-634-4694
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33491300Medicaid
WI33491300Medicaid
WI77042Medicare ID - Type Unspecified