Provider Demographics
NPI:1043470214
Name:WAGNER, RICHARD W JR (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:123 W FRANKLIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-2524
Mailing Address - Country:US
Mailing Address - Phone:919-967-9291
Mailing Address - Fax:919-942-4446
Practice Address - Street 1:123 W FRANKLIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-2524
Practice Address - Country:US
Practice Address - Phone:919-967-9291
Practice Address - Fax:919-942-4446
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC77011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
098741004OtherADA
NCAW6093758OtherDEA