1225019201 NPI number — DR. BRADLEY DUANE WAGONER DDS

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	WAGONER
Provider First Name	:	BRADLEY
Provider Middle Name	:	DUANE
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	DDS
Provider Gender Code	:	M

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Provider Other Organization Name Type Code	:
Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
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Provider Other Name Suffix Text	:
Provider Other Credential Text	:
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NPI Number	:	1225019201
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/09/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
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Provider First Line Business Mailing Address	:	3400 CROWN AVE
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	MARION
Provider Business Mailing Address State Name	:	IA
Provider Business Mailing Address Postal Code	:	523021446
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	3193730322
Provider Business Mailing Address Fax Number	:

Provider First Line Business Practice Location Address	:	955 31ST ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	MARION
Provider Business Practice Location Address State Name	:	IA
Provider Business Practice Location Address Postal Code	:	523023788
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	3193774867
Provider Business Practice Location Address Fax Number	:	3193774383
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 1223G0001X , with the licence number:  6894 , registered in the state of IA .

• Identifier: 0207225 , issued by the state of ( IA ) . This identifiers is of the category "".