Healthcare Provider Details

I. General information

NPI: 1275910978
Provider Name (Legal Business Name): MICHAEL STEPHEN PAGANO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10120 W BROAD ST STE I
GLEN ALLEN VA
23060-6709
US

IV. Provider business mailing address

10120 W BROAD ST STE I
GLEN ALLEN VA
23060-6709
US

V. Phone/Fax

Practice location:
  • Phone: 804-625-4064
  • Fax: 804-625-4066
Mailing address:
  • Phone: 804-625-4064
  • Fax: 804-625-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401415999
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401415999
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: