# F JOHN WAGNER

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1568522910
- **Authorized official:** DR. FREDERIC JOHN WAGNER DDS (PRES)
- **Authorized official phone:** (989) 544-2096

## Contact information

- **Practice address:** 7791 MYSTIC LAKE DR, LAKE, MI 48632-9743
- **Practice address phone:** (989) 544-2096
- **Mailing address:** 7791 MYSTIC LAKE DR, LAKE, MI 48632-9743
- **Mailing address phone:** (989) 544-2096

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | 10266 | MI | Yes |

## Other

- **Enumeration date:** 12/08/2006
- **Last updated:** 08/22/2020