Provider Demographics
NPI:1790381622
Name:WAGNER, CHAD LOWELL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:LOWELL
Last Name:WAGNER
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 1:301 FISHER ST
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:651-600-7104
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:651-600-7104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11918999-2903204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery