Healthcare Provider Details

I. General information

NPI: 1932332285
Provider Name (Legal Business Name): STEPHEN A. WAGNER DDS,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE STE A3
ALBUQUERQUE NM
87102-2639
US

IV. Provider business mailing address

801 ENCINO PL NE STE A3
ALBUQUERQUE NM
87102-2639
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 Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD1150
License Number StateNM

VIII. Authorized Official

Name: DR. STEPHEN A WAGNER
Title or Position: MAXILLOFACIAL PROSTHODONTIST
Credential: DDS,PC
Phone: 505-232-3588