Provider Demographics
NPI:1538500517
Name:WINGATE, KENNETH BRYAN JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRYAN
Last Name:WINGATE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 N TRENHOLM RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3211
Mailing Address - Country:US
Mailing Address - Phone:803-782-0965
Mailing Address - Fax:803-782-3404
Practice Address - Street 1:5309 N TRENHOLM RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-3211
Practice Address - Country:US
Practice Address - Phone:803-782-0965
Practice Address - Fax:803-782-3404
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice