MEDICARE: WAGNER, KUNTZ & GRABOUSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6637	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043402894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGNER, KUNTZ & GRABOUSKI

Provider Business Mailing Address
First Line	:	3021 HAMILTON BLVD
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-2407
Country	:	US
Telephone Number	:	712-258-0501
Fax Number	:	712-258-1461

Provider Business Practice Location Address
First Line	:	3021 HAMILTON BLVD
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-2407
Country	:	US
Telephone Number	:	712-258-0501
Fax Number	:	712-258-1461

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. RICHARD WAGNER
Credential	:	DDS
Telephone Number	:	712-258-0501

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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