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General NPI Number Information
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NPI Number | 1043402894
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Entity Type | Organization
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Legal Business Name | WAGNER, KUNTZ & GRABOUSKI
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Dates
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Enumeration Date | 08/15/2007
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Last Update Date | 08/15/2007
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Provider Practice Location Address
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Address Line | 3021 HAMILTON BLVD
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City | SIOUX CITY
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State | IA
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Zip | 51104-2407
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Country | US
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Telephone | 712-258-0501
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Fax | 712-258-1461
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Provider Business Mailing Address
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Address Line | 3021 HAMILTON BLVD
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City | SIOUX CITY
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State | IA
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Zip | 51104-2407
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Country | US
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Telephone | 712-258-0501
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Fax | 712-258-1461
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. RICHARD WAGNER
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Credential | DDS
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Telephone | 712-258-0501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 6637
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License Number State | IA
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