Provider Demographics
NPI:1215048806
Name:WAGUESPACK, KATHLEEN ELIZABETH (DMD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:WAGUESPACK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:9358 DORCHESTER ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-5606
Mailing Address - Country:US
Mailing Address - Phone:303-791-4400
Mailing Address - Fax:
Practice Address - Street 1:9358 DORCHESTER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-5606
Practice Address - Country:US
Practice Address - Phone:303-791-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002019801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022868Medicaid
943096772OtherTAX ID
TX25090OtherTEXAS BOARD OF DENTAL EXAMINERS
ORD8770OtherDENTAL LICENSE
CODEN.00201980OtherDORA
CODEN.00201980OtherDORA