Healthcare Provider Details

I. General information

NPI: 1093715963
Provider Name (Legal Business Name): LLYNDALL RHETT FAGG DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 MEDICAL PLZ
MICHIGAN CITY IN
46360-3364
US

IV. Provider business mailing address

211 MEDICAL PLZ
MICHIGAN CITY IN
46360-3364
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-4559
  • Fax: 219-879-4559
Mailing address:
  • Phone: 219-879-4559
  • Fax: 219-879-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12007148A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: