Provider Demographics
NPI:1164716569
Name:WAGUESPACK, CHARLES JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAMES
Last Name:WAGUESPACK
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:PO BOX E
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:LA
Mailing Address - Zip Code:70375-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 JOHNNY DUFRENE DR
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-2611
Practice Address - Country:US
Practice Address - Phone:985-532-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice