Healthcare Provider Details

I. General information

NPI: 1740695527
Provider Name (Legal Business Name): ADAM PETER FAGIN D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N SAN MATEO DR STE 600
SAN MATEO CA
94401-2675
US

IV. Provider business mailing address

235 N SAN MATEO DR STE 600
SAN MATEO CA
94401-2675
US

V. Phone/Fax

Practice location:
  • Phone: 650-342-0213
  • Fax:
Mailing address:
  • Phone: 650-342-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2020-00843
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number103519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: