Healthcare Provider Details

I. General information

NPI: 1760553614
Provider Name (Legal Business Name): RONALD J FAGAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 W MAIN ST
INVERNESS FL
34450
US

IV. Provider business mailing address

10662 HALLS RIVER RD
HOMOSASSA FL
34448
US

V. Phone/Fax

Practice location:
  • Phone: 352-344-2275
  • Fax: 352-344-1416
Mailing address:
  • Phone: 352-621-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN11969
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: