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NPI Code Detail

MEDICARE: DR. TIM R FAGAN DDS, MS

MEDICARE: DR. TIM R FAGAN DDS, MS
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
11223P0221XPediatric Dentistry4227OK

General Provider Information

NPI Number : 1477557452
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TIM R FAGAN DDS, MS
Provider Business Mailing Address
First Line : 423 N VAN BUREN ST
Second Line :
City : ENID
State : OK
Zip : 73703-4454
Country : US
Telephone Number : 580-233-0043
Fax Number :
Provider Business Practice Location Address
First Line : 1201 N STONEWALL AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73117-1214
Country : US
Telephone Number : 405-271-5444
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2005
Last Update Date : 07/24/2019

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