Provider Demographics
NPI:1205045275
Name:WAGGENER, ELIZABETH M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:M
Last Name:WAGGENER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8845 OAK HEDGE CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6957
Mailing Address - Country:US
Mailing Address - Phone:901-758-2537
Mailing Address - Fax:
Practice Address - Street 1:305 LAKE DR
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9718
Practice Address - Country:US
Practice Address - Phone:901-465-2714
Practice Address - Fax:901-465-6266
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist