Provider Demographics
NPI:1649404823
Name:WIGGER, THOMAS LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LOUIS
Last Name:WIGGER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40228-2096
Mailing Address - Country:US
Mailing Address - Phone:502-969-9300
Mailing Address - Fax:502-969-0630
Practice Address - Street 1:6500 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-2096
Practice Address - Country:US
Practice Address - Phone:502-969-9300
Practice Address - Fax:502-969-0630
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60047321Medicaid