Healthcare Provider Details

I. General information

NPI: 1841539905
Provider Name (Legal Business Name): DAVID ALAN WAGNER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N LEROY ST
FENTON MI
48430-2734
US

IV. Provider business mailing address

201S MICHIGAN AVE
BIG RAPIDS MI
49307-1809
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-8272
  • Fax: 810-629-3218
Mailing address:
  • Phone: 231-796-4747
  • Fax: 231-796-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS038617
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901020879
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: