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General NPI Number Information
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NPI Number | 1205897378
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Entity Type | Organization
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Legal Business Name | SPENCER B WAGNER DMD PC
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Dates
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Enumeration Date | 03/29/2006
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Last Update Date | 10/07/2008
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Provider Practice Location Address
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Address Line | 1987 ALLENDALE FAIRFAX HWY
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City | FAIRFAX
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State | SC
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Zip | 29827-9137
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Country | US
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Telephone | 803-632-3301
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Fax | 803-632-1240
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Provider Business Mailing Address
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Address Line | PO BOX 830
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City | FAIRFAX
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State | SC
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Zip | 29827-0830
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Country | US
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Telephone | 803-632-3301
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Fax | 803-632-1240
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Authorized Official
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Title or Position | DENTIST
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Name | SPENCER B WAGNER
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Credential | DMD
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Telephone | 803-632-3301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3192
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License Number State | SC
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