Provider Demographics
NPI:1841539905
Name:WAGNER, DAVID ALAN (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
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 1:201S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-1809
Mailing Address - Country:US
Mailing Address - Phone:231-796-4747
Mailing Address - Fax:231-796-5711
Practice Address - Street 1:500 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2734
Practice Address - Country:US
Practice Address - Phone:810-629-8272
Practice Address - Fax:810-629-3218
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0386171223P0700X
MI29010208791223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics