Healthcare Provider Details

I. General information

NPI: 1245325455
Provider Name (Legal Business Name): W.J. HAGERTY DENTAL OFFICES OF MONTGOMERY COUNTY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N. BROADWAY
TROTWOOD OH
45426
US

IV. Provider business mailing address

321 N. BROADWAY
TROTWOOD OH
45426
US

V. Phone/Fax

Practice location:
  • Phone: 937-837-8412
  • Fax: 837-854-3158
Mailing address:
  • Phone: 937-837-8412
  • Fax: 837-854-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30016938
License Number StateOH

VIII. Authorized Official

Name: NEVADA D ENDICOTT
Title or Position: BUSINESS MANAGER
Credential:
Phone: 937-837-1888