Provider Demographics
NPI:1679600944
Name:WAGNER, ROBERT LINTON (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LINTON
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 825
Mailing Address - Street 2:1402 ARGILLITE ROAD
Mailing Address - City:FLATWOODS
Mailing Address - State:KY
Mailing Address - Zip Code:41139
Mailing Address - Country:US
Mailing Address - Phone:606-836-1646
Mailing Address - Fax:606-836-0030
Practice Address - Street 1:1402 ARGILLITE ROAD
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139
Practice Address - Country:US
Practice Address - Phone:606-836-1646
Practice Address - Fax:606-836-0030
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY4649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60046497Medicaid