Healthcare Provider Details

I. General information

NPI: 1316095755
Provider Name (Legal Business Name): FLOYD BAGWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 PENNSYLVANIA AVE 302
FORESTVILLE MD
20747-4701
US

IV. Provider business mailing address

6613 ALLENTOWN RD
TEMPLE HILLS MD
20748-2723
US

V. Phone/Fax

Practice location:
  • Phone: 301-568-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13128
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: