MEDICARE: F JOHN WAGNER

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	261QD0000X	Dental Clinic/Center	10266	MI

General Provider Information

NPI Number	:	1568522910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	F JOHN WAGNER

Provider Business Mailing Address
First Line	:	7791 MYSTIC LAKE DR
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-9743
Country	:	US
Telephone Number	:	989-544-2096
Fax Number	:

Provider Business Practice Location Address
First Line	:	7791 MYSTIC LAKE DR
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-9743
Country	:	US
Telephone Number	:	989-544-2096
Fax Number	:

Authorized Official
Title or Position	:	PRES
Name	:	DR. FREDERIC JOHN WAGNER
Credential	:	DDS
Telephone Number	:	989-544-2096

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	08/22/2020

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