Healthcare Provider Details

I. General information

NPI: 1740368935
Provider Name (Legal Business Name): ROBERT GENE WAGONER II DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N. ELM STREET
HENDERSON KY
42420-2705
US

IV. Provider business mailing address

801 N. ELM STREET
HENDERSON KY
42420-2705
US

V. Phone/Fax

Practice location:
  • Phone: 270-212-0330
  • Fax: 270-212-0332
Mailing address:
  • Phone: 270-212-0330
  • Fax: 270-212-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7298
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number7298
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: