MEDICARE: DR. WILLIAM SCOTT WAGNER D.M.D., P.A.

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	DN14961	FL

General Provider Information

NPI Number	:	1760535587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM SCOTT WAGNER D.M.D., P.A.

Provider Business Mailing Address
First Line	:	1400 MARSH LANDING PKWY
Second Line	:	SUITE 104
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-2493
Country	:	US
Telephone Number	:	904-834-3737
Fax Number	:	904-758-0545

Provider Business Practice Location Address
First Line	:	1400 MARSH LANDING PKWY
Second Line	:	SUITE 104
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-2493
Country	:	US
Telephone Number	:	904-834-3737
Fax Number	:	904-758-0545

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	03/28/2014

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