MEDICARE: DR. DAWN MARIE WAGNER DMD, FAGD

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	DS029369L	PA

General Provider Information

NPI Number	:	1699754028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAWN MARIE WAGNER DMD, FAGD

Provider Business Mailing Address
First Line	:	7050 AIR DEPOT BLVD
Second Line	:
City	:	TINKER AFB
State	:	OK
Zip	:	73145-8716
Country	:	US
Telephone Number	:	405-582-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	7050 AIR DEPOT BLVD
Second Line	:
City	:	TINKER AFB
State	:	OK
Zip	:	73145-8716
Country	:	US
Telephone Number	:	405-582-6400
Fax Number	:

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

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	10/23/2019

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