Basic Information
| Provider Information | |||||||||
| NPI: | 1659545184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 HANCOCK CT | ||||||||
| Address2: | |||||||||
| City: | DEPTFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080965122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158373658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 E LEHIGH AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191251012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073613 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 04/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DS036569 | PA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.