GARY W WAGNER DMD Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****09

License Status

NOT RENEWED

Business

First Name

GARY W

Last Name

WAGNER

Suffix

DMD

Business Name

GARY W WAGNER DMD

Original Issue Date

07/13/1989

Effective Date

07/13/1989

Expiration Date

09/30/1992

City

SPRINGFIELD

State

Zip

62703

County

SANGAMON

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

10/13/2005