Provider Demographics
NPI:1043359417
Name:WAGNER, FREDERIC (DDS)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S COCHRAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813
Mailing Address - Country:US
Mailing Address - Phone:517-543-3810
Mailing Address - Fax:517-543-3899
Practice Address - Street 1:229 S COCHRAN AVENUE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813
Practice Address - Country:US
Practice Address - Phone:517-543-3810
Practice Address - Fax:517-543-3899
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI102661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice