MEDICARE: FREDERICK H. WAGGENER DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	10188	FL

General Provider Information

NPI Number	:	1215159058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDERICK H. WAGGENER DDS PA

Provider Business Mailing Address
First Line	:	115 PARNELL ST
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4715
Country	:	US
Telephone Number	:	321-452-8190
Fax Number	:	321-454-4822

Provider Business Practice Location Address
First Line	:	115 PARNELL ST
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4715
Country	:	US
Telephone Number	:	321-452-8190
Fax Number	:	321-454-4822

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FREDERICK H WAGGENER
Credential	:	DDS
Telephone Number	:	321-452-8190

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/22/2020

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