Organization
GREEN RIVER ORAL SURGERY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT GENE WAGONER II D.M.D., M.D (OWNER)
(570) 814-3085
Entity
Organization
Contact information
Practice address
801 N ELM ST, HENDERSON, KY 42420-2705
(270) 212-0330
(270) 212-0332
Mailing address
801 N ELM ST, HENDERSON, KY 42420-2705
(270) 212-0330
(270) 212-0332
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
7298
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64063514
—
KY
Enumeration date
08/13/2012
Last updated
08/13/2012
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