Provider Demographics
NPI:1982285771
Name:ROBERT J WAGNER DDS, INC.
Entity Type:Organization
Organization Name:ROBERT J WAGNER DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-799-9988
Mailing Address - Street 1:328 COMMERCIAL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3766
Mailing Address - Country:US
Mailing Address - Phone:909-799-9988
Mailing Address - Fax:
Practice Address - Street 1:328 COMMERCIAL RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3766
Practice Address - Country:US
Practice Address - Phone:909-799-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental