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General NPI Number Information
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NPI Number | 1629194964
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Entity Type | Organization
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Legal Business Name | PETER C. WAGNER, D.M.D., P.S.
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1292 S MARKET BLVD
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City | CHEHALIS
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State | WA
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Zip | 98532-3645
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Country | US
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Telephone | 360-748-6636
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Fax | 360-748-3176
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Provider Business Mailing Address
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Address Line | 1292 S MARKET BLVD
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City | CHEHALIS
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State | WA
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Zip | 98532-3645
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Country | US
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Telephone | 360-748-6636
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Fax | 360-748-3176
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Authorized Official
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Title or Position | PRESIDENT
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Name | PETER C. WAGNER
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Credential | D.M.D., P.S.
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Telephone | 360-748-6636
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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 | 6937
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License Number State | WA
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