Provider Demographics
NPI:1629166798
Name:WAGGENER, THOMAS WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILSON
Last Name:WAGGENER
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 1:4535 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1814
Mailing Address - Country:US
Mailing Address - Phone:254-776-7622
Mailing Address - Fax:254-776-7673
Practice Address - Street 1:4535 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1814
Practice Address - Country:US
Practice Address - Phone:254-776-7622
Practice Address - Fax:254-776-7673
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0086746-01Medicaid