Provider Demographics
NPI:1902909005
Name:WAGNER, SCOTT WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
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 1:9035 E 62ND ST SO
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-622-3915
Mailing Address - Fax:918-994-6870
Practice Address - Street 1:9035 EAST 62ND STREET SOUTH
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-622-3915
Practice Address - Fax:918-662-3922
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK974869Medicare ID - Type Unspecified