Healthcare Provider Details

I. General information

NPI: 1184701815
Provider Name (Legal Business Name): DAVID KEITH FAGUNDES D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: D. K. FAGUNDES D.M.D., M.S., P.C.

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PARKER DR SUITE A
LAGRANGE GA
30240-6436
US

IV. Provider business mailing address

105 PARKER DR SUITE A
LAGRANGE GA
30240-6436
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-3636
  • Fax: 706-884-8490
Mailing address:
  • Phone: 706-884-3636
  • Fax: 706-884-8490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4564
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number11435
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: