Provider Demographics
NPI:1174664460
Name:LEHMAN WAGGENER PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:LEHMAN WAGGENER PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JOHANNA
Authorized Official - Last Name:WAGGENER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:707-538-3325
Mailing Address - Street 1:80 DOCTORS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-544-1836
Mailing Address - Fax:707-542-0617
Practice Address - Street 1:80 DOCTORS PARK DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-544-1836
Practice Address - Fax:707-542-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty