# DRS. WAGONER & WAGONER, PC

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

## Provider details

- **NPI number:** 1932318995
- **Authorized official:** DR. GORDON D. WAGONER DDS, MAGD (PRESIDENT)
- **Authorized official phone:** (574) 967-4434

## Contact information

- **Practice address:** 17 S DIVISION ST, FLORA, IN 46929-1335
- **Practice address phone:** (574) 967-4434
- **Practice address fax:** (574) 967-4426
- **Mailing address:** 17 S DIVISION ST, FLORA, IN 46929-1335
- **Mailing address phone:** (574) 967-4434
- **Mailing address fax:** (574) 967-4426

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 12007394 | IN | Yes |
| 1223G0001X | General Practice Dentistry | 12009376 | IN | — |

## Other

- **Enumeration date:** 05/22/2007
- **Last updated:** 08/22/2020