Healthcare Provider Details

I. General information

NPI: 1982760153
Provider Name (Legal Business Name): CHARLES ALLEN WAGNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 VALENCIA DR
IDAHO FALLS ID
83404-7597
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 855-433-6825
  • Fax:
Mailing address:
  • Phone: 503-952-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2971138
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7442
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: