Provider Demographics
NPI:1235115833
Name:WAGLEY, CRAIG A (DDS MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:WAGLEY
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 MAHONING AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2437
Mailing Address - Country:US
Mailing Address - Phone:330-792-2501
Mailing Address - Fax:330-792-9249
Practice Address - Street 1:5437 MAHONING AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2437
Practice Address - Country:US
Practice Address - Phone:330-792-2501
Practice Address - Fax:330-792-9249
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21078204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2134630Medicaid
OHWA0880641Medicare PIN
G97345Medicare UPIN
OH2134630Medicaid
OHWA0880642Medicare PIN