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General NPI Number Information
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NPI Number | 1750638334
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Entity Type | Organization
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Legal Business Name | GREEN RIVER ORAL SURGERY
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Dates
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Enumeration Date | 08/13/2012
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Last Update Date | 08/13/2012
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Provider Practice Location Address
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Address Line | 801 N ELM ST
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City | HENDERSON
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State | KY
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Zip | 42420-2705
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Country | US
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Telephone | 270-212-0330
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Fax | 270-212-0332
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Provider Business Mailing Address
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Address Line | 801 N ELM ST
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City | HENDERSON
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State | KY
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Zip | 42420-2705
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Country | US
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Telephone | 270-212-0330
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Fax | 270-212-0332
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT GENE WAGONER II
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Credential | D.M.D., M.D
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Telephone | 570-814-3085
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 7298
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License Number State | KY
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