Healthcare Provider Details

I. General information

NPI: 1306006390
Provider Name (Legal Business Name): LLOYD DENTON WAGGENER M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1166 NE DOUGLAS ST
LEES SUMMIT MO
64086-4602
US

IV. Provider business mailing address

1166 NE DOUGLAS ST
LEES SUMMIT MO
64086-4602
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-8018
  • Fax: 816-524-8049
Mailing address:
  • Phone: 816-524-8018
  • Fax: 816-524-8049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1424
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: