Basic Information
| Provider Information | |||||||||
| NPI: | 1750026746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RDH, PHDHP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95 | ||||||||
| Address2: | |||||||||
| City: | SUMMIT STATION | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179790095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706401405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1110 ROCKLAND ST | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196041501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109884838 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2022 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | Y | Dental Providers | Dental Hygienist |
No ID Information.