Healthcare Provider Details

I. General information

NPI: 1538234695
Provider Name (Legal Business Name): RICHARD AGNEW FAGIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N SAN MATEO DR SUITE 600
SAN MATEO CA
94401
US

IV. Provider business mailing address

235 N SAN MATEO DR SUITE 600
SAN MATEO CA
94401
US

V. Phone/Fax

Practice location:
  • Phone: 650-342-0213
  • Fax: 650-342-0636
Mailing address:
  • Phone: 650-342-0213
  • Fax: 650-342-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD20691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: