=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477783728
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS J BAGLEY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2009
-----------------------------------------------------
Last Update Date | 05/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2729 HORSE PEN CREEK RD SUITE 103
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-8395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-854-5850
-----------------------------------------------------
Fax | 336-854-1054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2729 HORSE PEN CREEK RD SUITE 103
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-8395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-854-5850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8931
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------