Healthcare Provider Details

I. General information

NPI: 1174660856
Provider Name (Legal Business Name): HAROLD HARVEY FAGAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE SUITE 300
ALEXANDRIA VA
22304-1313
US

IV. Provider business mailing address

4660 KENMORE AVE SUITE 300
ALEXANDRIA VA
22304-1313
US

V. Phone/Fax

Practice location:
  • Phone: 703-823-2422
  • Fax: 703-842-8671
Mailing address:
  • Phone: 703-823-2422
  • Fax: 703-842-8671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401004958
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: