Healthcare Provider Details

I. General information

NPI: 1033361993
Provider Name (Legal Business Name): M. ALAN BAGDEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVENUE SUITE 104
SPRINGFIELD VA
22150-6120
US

IV. Provider business mailing address

6120 BRANDON AVENUE SUITE 104
SPRINGFIELD VA
22150-6120
US

V. Phone/Fax

Practice location:
  • Phone: 703-451-3900
  • Fax: 703-451-7912
Mailing address:
  • Phone: 703-451-3900
  • Fax: 703-451-7912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5364
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: