=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164716569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES JAMES WAGUESPACK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2011
-----------------------------------------------------
Last Update Date | 06/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 JOHNNY DUFRENE DR
-----------------------------------------------------
City | RACELAND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70394-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-532-5303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX E
-----------------------------------------------------
City | MATHEWS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70375-0429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6170
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------