Healthcare Provider Details

I. General information

NPI: 1386854891
Provider Name (Legal Business Name): JAY VICTOR EAGAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17600 WEST 12 MILE ROAD SUITE 4
SOUTHFIELD MI
48076
US

IV. Provider business mailing address

17600 WEST 12 MILE ROAD SUITE 4
SOUTHFIELD MI
48076
US

V. Phone/Fax

Practice location:
  • Phone: 248-569-8770
  • Fax: 248-569-2476
Mailing address:
  • Phone: 248-569-8770
  • Fax: 248-569-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13440
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: