Provider Demographics
NPI:1427582964
Name:WAGLEY, NEILSON LANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:NEILSON
Middle Name:LANE
Last Name:WAGLEY
Suffix:
Gender:M
Credentials:DMD
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:
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:
Practice Address - Street 1:5437 MAHONING AVE
Practice Address - Street 2:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11222122300000X
OH30.0264031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11222OtherSTATE DENTAL LICENSE
OH30.026403OtherSTATE DENTAL LICENSE