Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | IA | |
N | 1223S0112X | Oral and Maxillofacial Surgeon | IA |
NPI | 1003876988 |
---|---|
Provider Name | Dr. Wayne F Wagner |
First Address | Park Ridge, IL 60068-1469 |
Second Address | Park Ridge, IL 60068-1469 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T37299 | (02) |