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General NPI Number Information
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NPI Number | 1528419074
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Entity Type | Individual
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Provider Name | MARK VINCENT WAGNER DMD
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Gender | Male
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Dates
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Enumeration Date | 06/27/2016
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Last Update Date | 08/18/2020
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Provider Practice Location Address
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Address Line | 2600 VILLAGE PKWY STE 120
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City | HIGHLAND VILLAGE
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State | TX
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Zip | 75077-3285
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Country | US
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Telephone | 469-444-6500
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Fax | 972-317-0777
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Provider Business Mailing Address
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Address Line | 2600 VILLAGE PKWY STE 120
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City | HIGHLAND VILLAGE
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State | TX
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Zip | 75077-3285
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Country | US
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Telephone | 469-444-6500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 34961
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD4556
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License Number State | NM
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