Healthcare Provider Details

I. General information

NPI: 1235386459
Provider Name (Legal Business Name): WAGNER & SCHUMAN DENTAL OFFICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WYOMING BLVD NE
ALBUQUERQUE NM
87123-1029
US

IV. Provider business mailing address

201 WYOMING BLVD NE
ALBUQUERQUE NM
87123-1029
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-5881
  • Fax:
Mailing address:
  • Phone: 505-266-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDD788
License Number StateNM

VIII. Authorized Official

Name: DR. MAX WAGNER
Title or Position: PARTNER
Credential: D.O.
Phone: 505-266-5881