Provider Demographics
NPI:1871620641
Name:WAGNER, WOODROW WILSON III (DMD)
Entity type:Individual
Prefix:DR
First Name:WOODROW
Middle Name:WILSON
Last Name:WAGNER
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 S MAIN ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5504
Mailing Address - Country:US
Mailing Address - Phone:435-674-9777
Mailing Address - Fax:
Practice Address - Street 1:754 S MAIN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5504
Practice Address - Country:US
Practice Address - Phone:435-674-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145542-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice