Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | WA |
NPI | 1083700231 |
---|---|
Provider Name | Mrs. Alexis Dawn Wagoner |
First Address | Longview, WA 98632-4911 |
Second Address | Longview, WA 98632-4911 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2006 |
Last Update Date | 08/07/2007 |