Provider Demographics
NPI:1982776712
Name:WAGNER, LISA ANN (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 PARIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6144
Mailing Address - Country:US
Mailing Address - Phone:770-399-1582
Mailing Address - Fax:
Practice Address - Street 1:1130 SANCTUARY PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-4839
Practice Address - Country:US
Practice Address - Phone:770-641-5168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist