Organization
CUSTOM DENTAL CARE, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DENNIS RYAN WAGNER D.M.D. (OWNER/PRESIDENT)
(217) 430-1429
Entity
Organization
Contact information
Practice address
3740 E LAKE CTR STE B, QUINCY, IL 62305-5805
(217) 214-4545
(217) 214-4546
Mailing address
3740 E LAKE CTR STE B, QUINCY, IL 62305-5805
(217) 214-4545
(217) 214-4546
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019027406
IL
Other
Enumeration date
10/17/2012
Last updated
10/17/2012
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