Provider Demographics
NPI:1912087297
Name:WAGNER, DENNIS H (DPH)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:H
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 N ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5246
Mailing Address - Country:US
Mailing Address - Phone:405-789-6881
Mailing Address - Fax:405-787-9793
Practice Address - Street 1:2703 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5246
Practice Address - Country:US
Practice Address - Phone:405-789-6881
Practice Address - Fax:405-787-9793
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-4168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1-4168OtherSTATE LICENSE
OK0730450001Medicare ID - Type Unspecified