Healthcare Provider Details

I. General information

NPI: 1225254618
Provider Name (Legal Business Name): STANISLAUS JEAN WAGUESPACK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4906 AMBASSADOR CAFFERY PKWY BLDG L
LAFAYETTE LA
70508-6962
US

IV. Provider business mailing address

4906 AMBASSADOR CAFFERY PKWY BLDG L
LAFAYETTE LA
70508-6962
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-3677
  • Fax:
Mailing address:
  • Phone: 337-233-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5218
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: