Provider Demographics
NPI:1205897378
Name:SPENCER B WAGNER DMD PC
Entity type:Organization
Organization Name:SPENCER B WAGNER DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-632-3301
Mailing Address - Street 1:PO BOX 830
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-0830
Mailing Address - Country:US
Mailing Address - Phone:803-632-3301
Mailing Address - Fax:803-632-1240
Practice Address - Street 1:1987 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9137
Practice Address - Country:US
Practice Address - Phone:803-632-3301
Practice Address - Fax:803-632-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3192261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental