# NICHOLAS J WAGNER, DDS, LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Warrick Park Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1306231717
- **Authorized official:** DR. NICHOLAS J WAGNER DDS (DENTIST/OWNER)
- **Authorized official phone:** (812) 897-4889

## Contact information

- **Practice address:** 800 OFFICE PARK DR, BOONVILLE, IN 47601-8601
- **Practice address phone:** (812) 897-4889
- **Mailing address:** 800 OFFICE PARK DR, BOONVILLE, IN 47601-8601
- **Mailing address phone:** (812) 897-4889

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 12011465A | IN | Yes |

## Other

- **Enumeration date:** 04/02/2015
- **Last updated:** 04/02/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1023338480 | — | IN |
| 05 | — | 1588740815 | — | IN |