Provider Demographics
NPI:1982803920
Name:WAGNER, DENNIS RYAN (DMD)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:RYAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 COUNTRY CLUB HEIGHTS
Mailing Address - Street 2:APT 103
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301
Mailing Address - Country:US
Mailing Address - Phone:217-221-8534
Mailing Address - Fax:
Practice Address - Street 1:407 SOUTH 48TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305
Practice Address - Country:US
Practice Address - Phone:217-228-9467
Practice Address - Fax:217-228-0131
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice