=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902943657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM W WAGNILD DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 10/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10976 CEDAR LAKE RD
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-3366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-544-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10976 CEDAR LAKE RD
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-3366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-544-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM WALTON WAGNILD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 952-544-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8960
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------