Healthcare Provider Details

I. General information

NPI: 1952422750
Provider Name (Legal Business Name): JAMES STEVEN FAGAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 RT 611 FOUNTAIN SPRINGS WEST SUITE 3
TANNERSVILLE PA
18444
US

IV. Provider business mailing address

PO BOX 700 3 1644 RT 611 FOUNTAIN SPRINGS WEST RR1 SUITE 3
TANNERSVILLE PA
18444
US

V. Phone/Fax

Practice location:
  • Phone: 570-620-1840
  • Fax: 570-620-1850
Mailing address:
  • Phone: 570-620-1840
  • Fax: 570-620-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS024640L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: