Healthcare Provider Details

I. General information

NPI: 1750638334
Provider Name (Legal Business Name): GREEN RIVER ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N ELM ST
HENDERSON KY
42420-2705
US

IV. Provider business mailing address

801 N ELM ST
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 TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7298
License Number StateKY

VIII. Authorized Official

Name: DR. ROBERT GENE WAGONER II
Title or Position: OWNER
Credential: D.M.D., M.D
Phone: 570-814-3085