MEDICARE: DR. MARK CHARLES FAGAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	38419	CA

General Provider Information

NPI Number	:	1376562827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK CHARLES FAGAN D.D.S.

Provider Business Mailing Address
First Line	:	1660 WILLOW ST
Second Line	:	STE #3
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5101
Country	:	US
Telephone Number	:	408-269-1060
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 WILLOW ST
Second Line	:	STE #3
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5101
Country	:	US
Telephone Number	:	408-269-1060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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