Individual
DR. KEVIN JOSEPH WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
921 S 8TH AVENUE STOP 8088, POCATELLO, ID 83201
(609) 923-0168
Mailing address
4170 HAWTHORNE RD APT A307, CHUBBUCK, ID 83202-2738
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D-5422
ID
Other
Enumeration date
07/07/2022
Last updated
07/07/2022
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