1063592798 NPI number — WILLIAM J. HAGERTY DDS INC

Table of content: (NPI 1063592798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063592798 NPI number — WILLIAM J. HAGERTY DDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM J. HAGERTY DDS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTERVILLE DENTAL ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063592798
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7058 CORPORATE WAY
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-433-8303
Provider Business Mailing Address Fax Number:
937-433-0795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7058 CORPORATE WAY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-433-8303
Provider Business Practice Location Address Fax Number:
937-433-0795
Provider Enumeration Date:
10/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ENDICOTT
Authorized Official First Name:
NEVADA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
937-837-1888

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  30016938 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)