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General NPI Number Information
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NPI Number | 1821403924
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Entity Type | Individual
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Provider Name | TESHA LYNN WAGGONER DMD
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Gender | Female
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Dates
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Enumeration Date | 06/26/2014
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Last Update Date | 08/27/2018
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Provider Practice Location Address
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Address Line | 150 SE 3RD AVE
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City | HILLSBORO
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State | OR
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Zip | 97123
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Country | US
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Telephone | 503-213-1257
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Fax | 503-213-1258
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Provider Business Mailing Address
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Address Line | 14201 NE 20TH AVE STE B200
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City | VANCOUVER
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State | WA
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Zip | 98686-6412
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Country | US
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Telephone | 360-571-8181
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Fax | 360-573-4022
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DTT 242
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D10820
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License Number State | OR
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