Healthcare Provider Details

I. General information

NPI: 1790381622
Provider Name (Legal Business Name): CHAD LOWELL WAGNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
BILOXI MS
39534-2508
US

IV. Provider business mailing address

301 FISHER ST
BILOXI MS
39534-2508
US

V. Phone/Fax

Practice location:
  • Phone: 651-600-7104
  • Fax:
Mailing address:
  • Phone: 651-600-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number111707
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number11918999-2903
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: