Healthcare Provider Details

I. General information

NPI: 1306231717
Provider Name (Legal Business Name): NICHOLAS J WAGNER, DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OFFICE PARK DR
BOONVILLE IN
47601-8601
US

IV. Provider business mailing address

800 OFFICE PARK DR
BOONVILLE IN
47601-8601
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-4889
  • Fax:
Mailing address:
  • Phone: 812-897-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12011465A
License Number StateIN

VIII. Authorized Official

Name: DR. NICHOLAS J WAGNER
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 812-897-4889