Provider Demographics
NPI:1902255631
Name:WAGGENER, STEPHANIE MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:WAGGENER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 HASPER DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3420
Mailing Address - Country:US
Mailing Address - Phone:616-481-0075
Mailing Address - Fax:
Practice Address - Street 1:7122 HAWICK CT NE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306-9688
Practice Address - Country:US
Practice Address - Phone:616-481-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist