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General NPI Number Information
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NPI Number | 1295259760
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Entity Type | Organization
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Legal Business Name | WAGGONER PROFESSIONAL SERVICES PC
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Dates
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Enumeration Date | 07/27/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 9575 W TROPICANA AVE STE 5
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City | LAS VEGAS
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State | NV
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Zip | 89147-8491
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Country | US
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Telephone | 702-633-8331
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Fax |
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Provider Business Mailing Address
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Address Line | 9575 W TROPICANA AVE STE 5
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City | LAS VEGAS
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State | NV
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Zip | 89147-8491
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Country | US
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Telephone | 702-633-8331
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | LISA ANTUNA
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Credential |
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Telephone | 702-254-4220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | S6-17
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License Number State |
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