Healthcare Provider Details

I. General information

NPI: 1154338101
Provider Name (Legal Business Name): JON DAGLEY WAGNER MD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 COORS BYP NW SUITE G-218
ALBUQUERQUE NM
87114-4040
US

IV. Provider business mailing address

10000 COORS BYP NW SUITE G-218
ALBUQUERQUE NM
87114-4040
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4867
  • Fax:
Mailing address:
  • Phone: 505-242-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number95-367
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD3842
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number28634
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number055441-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: