Provider Demographics
NPI:1376500322
Name:WIGGINS, GREGORY B (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:B
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 ASHLEY PHOSPHATE RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-4190
Mailing Address - Country:US
Mailing Address - Phone:843-569-1717
Mailing Address - Fax:843-569-6139
Practice Address - Street 1:2170 ASHLEY PHOSPHATE RD
Practice Address - Street 2:SUITE 600
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4190
Practice Address - Country:US
Practice Address - Phone:843-569-1717
Practice Address - Fax:843-569-6139
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC05131223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3375Medicaid