Provider Demographics
NPI:1881757854
Name:WAGGONER, CLYDE E (DMD)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:E
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 E EXPOSITION AVE
Mailing Address - Street 2:SUITE 520
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-5000
Mailing Address - Country:US
Mailing Address - Phone:303-777-1603
Mailing Address - Fax:
Practice Address - Street 1:3955 E EXPOSITION AVE
Practice Address - Street 2:SUITE 520
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-5000
Practice Address - Country:US
Practice Address - Phone:303-777-1603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO75061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery