Healthcare Provider Details

I. General information

NPI: 1639128887
Provider Name (Legal Business Name): JODY LYN DAGAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 S LINDSAY RD STE 101
GILBERT AZ
85296-6503
US

IV. Provider business mailing address

21821 N 40TH WAY
PHOENIX AZ
85050-7235
US

V. Phone/Fax

Practice location:
  • Phone: 480-292-9835
  • Fax: 480-292-9836
Mailing address:
  • Phone: 480-220-8970
  • Fax: 480-292-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1214
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: