Healthcare Provider Details

I. General information

NPI: 1336131267
Provider Name (Legal Business Name): STEPHEN A. WAGNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE SUITE A-3
ALBUQUERQUE NM
87102-2612
US

IV. Provider business mailing address

801 ENCINO PL NE SUITE A-3
ALBUQUERQUE NM
87102-2612
US

V. Phone/Fax

Practice location:
  • Phone: 505-232-3588
  • Fax: 505-232-3593
Mailing address:
  • Phone: 505-232-3588
  • Fax: 505-232-3593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1150
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: