Provider Demographics
NPI:1689061400
Name:WAILES, DUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:
Last Name:WAILES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932759
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0015
Mailing Address - Country:US
Mailing Address - Phone:317-614-9817
Mailing Address - Fax:317-614-9655
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-293-8228
Practice Address - Fax:937-293-8229
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139259207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology