| Doctor Name: | DR. CHARLES J WAGENER |
| NPI Number: | 1154335313 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.D.S., M.S. |
| License Number: | |
| Business Practice Address: | 1752 Windsor Rd Suite 204 Loves Park, IL - 611114280 |
| Business Phone Number: | 8152821900 |
| Business Fax Number: | |
| Mailing Address: | 1752 Windsor Rd, Suite 204 LOVES PARK |
| State: | IL |
| Postal Code: | 611114280 |
| Phone Number: | 8152821900 |
| Fax Number: | |
| NPI Enumeration Date: | 07/27/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Periodontics |
| Taxonomy Definition: | That specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues. |