MEDICARE: DR. RUDOLPH MICHAEL WAGNER D.M.D.

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	21125	FL

General Provider Information

NPI Number	:	1154556132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUDOLPH MICHAEL WAGNER D.M.D.

Provider Business Mailing Address
First Line	:	2595 TAMPA RD STE I
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3131
Country	:	US
Telephone Number	:	727-785-8847
Fax Number	:

Provider Business Practice Location Address
First Line	:	2595 TAMPA RD STE I
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3131
Country	:	US
Telephone Number	:	727-785-8847
Fax Number	:	277-785-9372

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	07/20/2021

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