Healthcare Provider Details

I. General information

NPI: 1063515302
Provider Name (Legal Business Name): RONALD J HAGGERTY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LINCOLN STREET
FORT ASHBY WV
26719
US

IV. Provider business mailing address

PO BOX 1060
FORT ASHBY WV
26719-1060
US

V. Phone/Fax

Practice location:
  • Phone: 304-298-3501
  • Fax: 304-298-3406
Mailing address:
  • Phone: 304-298-3501
  • Fax: 304-298-3406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2119
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: