MEDICARE: KENT WAGNER JR DDS PC

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	122300000X	Dentist	4799	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1779641	OTHER		UNITED CONCORIDA PROVIDER

General Provider Information

NPI Number	:	1336157270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENT WAGNER JR DDS PC

Provider Business Mailing Address
First Line	:	2045 VILLAGE CENTER CIRCLE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134
Country	:	US
Telephone Number	:	702-878-5599
Fax Number	:	702-878-0173

Provider Business Practice Location Address
First Line	:	2045 VILLAGE CENTER CIRCLE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134
Country	:	US
Telephone Number	:	702-878-5599
Fax Number	:	702-878-0173

Authorized Official
Title or Position	:	DENTIST OWNER
Name	:	RONALD KENT WAGNER JR.
Credential	:	DDS
Telephone Number	:	702-878-5599

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	08/22/2020

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