Healthcare Provider Details

I. General information

NPI: 1033804075
Provider Name (Legal Business Name): BREA FAGAN D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8730 CHERRY LN
LAUREL MD
20707-6212
US

IV. Provider business mailing address

6006 GRENFELL LOOP
BOWIE MD
20720-5343
US

V. Phone/Fax

Practice location:
  • Phone: 410-251-4932
  • Fax:
Mailing address:
  • Phone: 410-251-4932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18058
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: