Healthcare Provider Details

I. General information

NPI: 1679600944
Provider Name (Legal Business Name): ROBERT LINTON WAGNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 ARGILLITE ROAD
FLATWOODS KY
41139
US

IV. Provider business mailing address

PO BOX 825 1402 ARGILLITE ROAD
FLATWOODS KY
41139
US

V. Phone/Fax

Practice location:
  • Phone: 606-836-1646
  • Fax: 606-836-0030
Mailing address:
  • Phone: 606-836-1646
  • Fax: 606-836-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberKY4649
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: