Provider Demographics
NPI:1215159058
Name:FREDERICK H. WAGGENER DDS PA
Entity type:Organization
Organization Name:FREDERICK H. WAGGENER DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:H
Authorized Official - Last Name:WAGGENER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-452-8190
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty