GARY W WAGNER DMD Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****08

License Status

NOT RENEWED

Business

First Name

GARY W

Last Name

WAGNER

Suffix

DMD

Business Name

GARY W WAGNER DMD

Original Issue Date

07/10/1989

Effective Date

06/10/2009

Expiration Date

09/30/2012

City

SPRINGFIELD

State

Zip

62704

County

SANGAMON

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/14/2012