Healthcare Provider Details

I. General information

NPI: 1932635653
Provider Name (Legal Business Name): TRAVIS RAY WAGNER MAJ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MDG RAF LAKENHEATH
APO AE
09461
US

IV. Provider business mailing address

48TH MDG/RAF LAKENHEATH, APO, AE 09461 RAF LAKENHEATH
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 440-163-8528
  • Fax:
Mailing address:
  • Phone: 440-163-8528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401415734
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: