MEDICARE: RONALD KENT WAGNER JR. DDS

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	122300000X	Dentist	4799	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1779641	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1851309793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD KENT WAGNER JR. DDS

Provider Business Mailing Address
First Line	:	2045 VILLAGE CENTER CIRCLE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134
Country	:	US
Telephone Number	:	702-878-5599
Fax Number	:	702-878-0173

Provider Business Practice Location Address
First Line	:	2045 VILLAGE CENTER CIRCLE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134
Country	:	US
Telephone Number	:	702-878-5599
Fax Number	:	702-878-0173

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/08/2007

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