Healthcare Provider Details

I. General information

NPI: 1952855470
Provider Name (Legal Business Name): DAVID A WAGNER DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 EASTLAND BLVD SUITE 112
CLEARWATER FL
33761-4106
US

IV. Provider business mailing address

3023 EASTLAND BLVD SUITE 112
CLEARWATER FL
33761-4106
US

V. Phone/Fax

Practice location:
  • Phone: 727-797-5161
  • Fax: 727-797-5121
Mailing address:
  • Phone: 727-797-5161
  • Fax: 727-797-5121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN13625
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberDN13625
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID ALAN WAGNER
Title or Position: OWNER/DENTIST
Credential: D.D.S
Phone: 727-797-5161