Healthcare Provider Details

I. General information

NPI: 1205897378
Provider Name (Legal Business Name): SPENCER B WAGNER DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1987 ALLENDALE FAIRFAX HWY
FAIRFAX SC
29827-9137
US

IV. Provider business mailing address

PO BOX 830
FAIRFAX SC
29827-0830
US

V. Phone/Fax

Practice location:
  • Phone: 803-632-3301
  • Fax: 803-632-1240
Mailing address:
  • Phone: 803-632-3301
  • Fax: 803-632-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3192
License Number StateSC

VIII. Authorized Official

Name: SPENCER B WAGNER
Title or Position: DENTIST
Credential: DMD
Phone: 803-632-3301