Jon Dagley Wagner, MD DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

DD3842 Issued in NM

Practice address

10000 Coors Byp NW
Suite G-218
Albuquerque, NM 87114-4040

Phone

(505) 242-4867

NPI assigned

Aug 2, 2006

Last updated

Apr 4, 2013By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jul 23, 2019 through Jul 23, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Cottonwood Mall Dental Practice, LLC

  • Dental Clinic/Center
  • Albuquerque, NM
  • NPI 1043487119
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154476800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1365033600000",
    "number": "1154338101",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10000 COORS BYP NW",
            "address_2": "SUITE G-218",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871144040",
            "telephone_number": "505-242-4867"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10000 COORS BYP NW",
            "address_2": "SUITE G-218",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871144040",
            "telephone_number": "505-242-4867"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "JON",
        "middle_name": "DAGLEY",
        "credential": "MD DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-02",
        "last_updated": "2013-04-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NM",
            "license": "DD3842",
            "primary": true
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "TX",
            "license": "28634",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NY",
            "license": "055441-1",
            "primary": false
        },
        {
            "code": "208200000X",
            "taxonomy_group": "",
            "desc": "Plastic Surgery",
            "state": "TX",
            "license": "95-367",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Zo Wagner-Henninger
• Brianna Wagner, LMSW
• Diane Wagner, LISW
• Jeffrey Paul Wagner, DDS
• Jody Wagner, RN
• Laurie A Wagner, CRNA
• Linda A Wagner, AUD
• Richard Alfred Wagner
• Stephen A. Wagner, DDS
• William Frederick Wagner, MD

• Oral and Maxillofacial Surgery (Dentist) in Albuquerque, NM
• Providers in Albuquerque, NM by specialty
• Oral and Maxillofacial Surgery (Dentist) in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 4, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.