Kevin Joseph Wagner, DMD

Primary specialty

DentistTaxonomy code 122300000X

License

D-5422 Issued in ID

Practice address

921 S 8TH Avenue Stop 8088
Pocatello, ID 83201

Phone

(609) 923-0168

NPI assigned

Jul 7, 2022

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

Electronic endpoints 1

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": "1657152000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1657152000000",
    "number": "1558094508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4170 HAWTHORNE RD APT A307",
            "city": "CHUBBUCK",
            "state": "ID",
            "postal_code": "832022738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "921 S 8TH AVENUE STOP 8088",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "83201",
            "telephone_number": "609-923-0168"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "KEVIN",
        "middle_name": "JOSEPH",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-07-07",
        "last_updated": "2022-07-07",
        "certification_date": "2022-06-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "ID",
            "license": "D-5422",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "lippsusa@health.isu.edu",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "921 S 8th Avenue Stop 8088",
            "city": "Pocatello",
            "state": "ID",
            "country_code": "US",
            "postal_code": "83201",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• All providers in Pocatello, ID
• Dentist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2022; 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.