MEDICARE: CRAIG DEAGLE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	63280	CA

General Provider Information

NPI Number	:	1356500110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRAIG DEAGLE DMD

Provider Business Mailing Address
First Line	:	7900 EL CAJON BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-0607
Country	:	US
Telephone Number	:	617-834-4943
Fax Number	:

Provider Business Practice Location Address
First Line	:	7900 EL CAJON BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-0607
Country	:	US
Telephone Number	:	617-834-4943
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2008
Last Update Date	:	05/05/2014

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