Provider Demographics
NPI:1730212564
Name:WAGSTAFF, CHAD L (DDS)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:L
Last Name:WAGSTAFF
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 805
Mailing Address - Street 2:2640 N HIGHWAY 162
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2640 N HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310-9745
Practice Address - Country:US
Practice Address - Phone:801-745-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0252761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice