Jacob Ryan Wagner, D.D.S.

Primary specialty

DentistTaxonomy code 122300000X

License

6002171-15 Issued in WI

Practice address

8201 Mish Ko Swen Dr
Crandon, WI 54520-8631

Phone

(608) 206-9268

NPI assigned

Mar 19, 2026

Last updated

Jun 4, 2026By 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 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1773878400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1780531200000",
    "number": "1538017140",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8201 MISH KO SWEN DR",
            "city": "CRANDON",
            "state": "WI",
            "postal_code": "545208631",
            "telephone_number": "608-206-9268"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8201 MISH KO SWEN DR",
            "city": "CRANDON",
            "state": "WI",
            "postal_code": "545208631",
            "telephone_number": "608-206-9268"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "JACOB",
        "middle_name": "RYAN",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2026-03-19",
        "last_updated": "2026-06-04",
        "certification_date": "2026-06-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WI",
            "license": "6002171-15",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• The Center for Human Restoration, Inc
• Betty S Thunder, ADVANCED PRACTICE SO
• Kayla Charlene Van Cleve, RN
• Eve Louise Van Harpen, DDS
• Zatrina Marie Vollmar
• Renee Lynn Walden, OD
• Angela Kay Wales, DPT
• Diane K Walker, RN CDE
• Deborah Wendorf
• Lana Winter, SAC

• Dentist in Crandon, WI
• Providers in Crandon, WI by specialty
• Dentist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 4, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.