Healthcare Provider Details

I. General information

NPI: 1487628731
Provider Name (Legal Business Name): RANDY J FAGAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 W WASHINGTON ST
BROKEN ARROW OK
74012-6726
US

IV. Provider business mailing address

2221 W WASHINGTON ST
BROKEN ARROW OK
74012-6726
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-6406
  • Fax: 918-455-1856
Mailing address:
  • Phone: 918-455-6406
  • Fax: 918-455-1856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5318
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: