MEDICARE: DR. JOHN WILLIAM WAGNER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3745	WA

General Provider Information

NPI Number	:	1467452037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN WILLIAM WAGNER D.D.S.

Provider Business Mailing Address
First Line	:	7701 LAKEMONT DR NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-5234
Country	:	US
Telephone Number	:	206-523-7175
Fax Number	:

Provider Business Practice Location Address
First Line	:	2211 N 56TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-6203
Country	:	US
Telephone Number	:	206-632-1313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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