Provider Demographics
NPI:1083700231
Name:WAGONER, ALEXIS DAWN (DA)
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:DAWN
Last Name:WAGONER
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4911
Mailing Address - Country:US
Mailing Address - Phone:360-425-7753
Mailing Address - Fax:
Practice Address - Street 1:3902 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4911
Practice Address - Country:US
Practice Address - Phone:360-425-7753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant