Provider Demographics
NPI:1225253297
Name:WAGGENER, FREDERICK H (DDS)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:H
Last Name:WAGGENER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PARNELL ST
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4715
Mailing Address - Country:US
Mailing Address - Phone:321-452-8190
Mailing Address - Fax:321-454-4822
Practice Address - Street 1:115 PARNELL ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4715
Practice Address - Country:US
Practice Address - Phone:321-452-8190
Practice Address - Fax:321-454-4822
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice