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General NPI Number Information
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NPI Number | 1942450937
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Entity Type | Organization
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Legal Business Name | DAVID E WAGNER DMD LLC
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Dates
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Enumeration Date | 09/25/2008
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Last Update Date | 09/25/2008
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Provider Practice Location Address
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Address Line | 5992 HOWDERSHELL RD STE 206
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City | HAZELWOOD
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State | MO
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Zip | 63042-4107
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Country | US
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Telephone | 314-731-2273
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Fax | 314-731-2096
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Provider Business Mailing Address
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Address Line | 5992 HOWDERSHELL RD STE 206
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City | HAZELWOOD
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State | MO
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Zip | 63042-4107
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Country | US
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Telephone | 314-731-2273
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Fax | 314-731-2096
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. DAVID E WAGNER
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Credential | DMD
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Telephone | 314-731-2273
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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 | 14071
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License Number State | MO
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