Provider Demographics
NPI:1790558997
Name:TESHA WAGGONER DMD PC
Entity Type:Organization
Organization Name:TESHA WAGGONER DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TESHA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-292-9274
Mailing Address - Street 1:5415 SW WESTGATE DR.
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221
Mailing Address - Country:US
Mailing Address - Phone:503-292-9274
Mailing Address - Fax:503-445-0043
Practice Address - Street 1:5415 SW WESTGATE DR.
Practice Address - Street 2:SUITE 207
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221
Practice Address - Country:US
Practice Address - Phone:503-292-9274
Practice Address - Fax:503-445-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500748806Medicaid