Provider Demographics
NPI:1578541355
Name:WAGGONNER, MARK ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALBERT
Last Name:WAGGONNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12020 PARADISE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5335
Mailing Address - Country:US
Mailing Address - Phone:909-824-6251
Mailing Address - Fax:
Practice Address - Street 1:28401 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-3040
Practice Address - Country:US
Practice Address - Phone:951-679-6355
Practice Address - Fax:951-679-6355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA241891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice