MEDICARE: DEANA FUGATE, DMD, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8338	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1326027038	OTHER	NC	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1215114780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEANA FUGATE, DMD, P.A.

Provider Business Mailing Address
First Line	:	13500 NC HIGHWAY 50
Second Line	:	SUITE 104
City	:	SURF CITY
State	:	NC
Zip	:	28445-7934
Country	:	US
Telephone Number	:	910-329-0298
Fax Number	:	910-329-4498

Provider Business Practice Location Address
First Line	:	13500 NC HIGHWAY 50
Second Line	:	SUITE 104
City	:	SURF CITY
State	:	NC
Zip	:	28445-7934
Country	:	US
Telephone Number	:	910-329-0298
Fax Number	:	910-329-4498

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DEANA FUGATE
Credential	:	DMD
Telephone Number	:	910-329-0298

Provider Enumeration Date	:	01/28/2008
Last Update Date	:	01/28/2008

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