Healthcare Provider Details

I. General information

NPI: 1235115833
Provider Name (Legal Business Name): CRAIG A WAGLEY DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5437 MAHONING AVE SUITE 12
AUSTINTOWN OH
44515-2437
US

IV. Provider business mailing address

5437 MAHONING AVE SUITE 12
AUSTINTOWN OH
44515-2437
US

V. Phone/Fax

Practice location:
  • Phone: 330-792-2501
  • Fax: 330-792-9249
Mailing address:
  • Phone: 330-792-2501
  • Fax: 330-792-9249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number21078
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: