Healthcare Provider Details

I. General information

NPI: 1588612790
Provider Name (Legal Business Name): MARK W FAGAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10205 N RIVA RIDGE LOOP
FORT DRUM NY
13602-5457
US

IV. Provider business mailing address

120 MILL CREEK LN
SACKETS HARBOR NY
13685-9744
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-5088
  • Fax:
Mailing address:
  • Phone: 915-841-8661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number11964
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: