Individual
DR. NEILSON LANE WAGLEY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
5437 MAHONING AVE, AUSTINTOWN, OH 44515-2437
(330) 792-2501
Mailing address
5437 MAHONING AVE, AUSTINTOWN, OH 44515-2437
(330) 792-2501
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
11222
TN
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
30.026403
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11222
STATE DENTAL LICENSE
TN
01
—
30.026403
STATE DENTAL LICENSE
OH
Enumeration date
04/11/2017
Last updated
06/14/2021
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