Provider Demographics
NPI:1821403924
Name:WAGGONER, TESHA LYNN (DMD)
Entity Type:Individual
Prefix:
First Name:TESHA
Middle Name:LYNN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 NE 20TH AVE STE B200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-6412
Mailing Address - Country:US
Mailing Address - Phone:360-571-8181
Mailing Address - Fax:360-573-4022
Practice Address - Street 1:150 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-213-1257
Practice Address - Fax:503-213-1258
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDTT 242122300000X
ORD108201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist