Healthcare Provider Details

I. General information

NPI: 1265167985
Provider Name (Legal Business Name): CALIFORNIA DENTAL A WAGGONER DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ASPEN CT
VISALIA CA
93291-5175
US

IV. Provider business mailing address

9709 LAKESIDE BLVD STE 350
SPRING TX
77381-1216
US

V. Phone/Fax

Practice location:
  • Phone: 559-625-9300
  • Fax: 717-759-4336
Mailing address:
  • Phone: 713-489-2198
  • Fax: 713-489-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM WAGGONER
Title or Position: OWNER
Credential: DDS
Phone: 702-339-6729