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General NPI Number Information
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NPI Number | 1003216698
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Entity Type | Organization
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Legal Business Name | WAGNER DENTAL LLC
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 09/02/2014
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Provider Practice Location Address
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Address Line | 2045 VILLAGE CENTER CIR
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City | LAS VEGAS
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State | NV
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Zip | 89134-6251
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Country | US
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Telephone | 702-878-5599
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Fax | 702-878-0173
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Provider Business Mailing Address
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Address Line | 2045 VILLAGE CENTER CIR
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City | LAS VEGAS
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State | NV
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Zip | 89134-6251
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Country | US
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Telephone | 702-878-5599
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Fax | 702-878-0173
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Authorized Official
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Title or Position | MANAGER
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Name | RONALD KENT WAGNER JR.
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Credential | DDS
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Telephone | 702-878-5599
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | NV
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