Healthcare Provider Details

I. General information

NPI: 1417036625
Provider Name (Legal Business Name): THOMAS GEORGE FAGOT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N ADAMS ST
LEXINGTON NE
68850-1621
US

IV. Provider business mailing address

PO BOX 940
LEXINGTON NE
68850-0940
US

V. Phone/Fax

Practice location:
  • Phone: 308-324-7422
  • Fax:
Mailing address:
  • Phone: 308-324-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5151
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: