Healthcare Provider Details

I. General information

NPI: 1356500110
Provider Name (Legal Business Name): CRAIG DEAGLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 EL CAJON BLVD
LA MESA CA
91942-0607
US

IV. Provider business mailing address

7900 EL CAJON BLVD
LA MESA CA
91942-0607
US

V. Phone/Fax

Practice location:
  • Phone: 617-834-4943
  • Fax:
Mailing address:
  • Phone: 617-834-4943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number63280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: