Healthcare Provider Details

I. General information

NPI: 1073429007
Provider Name (Legal Business Name): AMY BHAGALOO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BROWN DENTAL CLINIC, BUILDING 4405 ON 5TH AVE
FORT RUCKER AL
36362
US

IV. Provider business mailing address

BROWN DENTAL CLINIC, BUILDING 4405 ON 5TH AVE
FORT RUCKER AL
36362
US

V. Phone/Fax

Practice location:
  • Phone: 860-994-0015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14290733-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: