Basic Information
| Provider Information | |||||||||
| NPI: | 1235115833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGLEY | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5437 MAHONING AVE | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | AUSTINTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445152437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307922501 | ||||||||
| FaxNumber: | 3307929249 | ||||||||
| Practice Location | |||||||||
| Address1: | 5437 MAHONING AVE | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | AUSTINTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445152437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307922501 | ||||||||
| FaxNumber: | 3307929249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | 21078 | OH | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2134630 | 05 | OH | MEDICAID |