1558317784 NPI number — DR. SHAN K BAGBY DMD

Table of content: DR. SHAN K BAGBY DMD (NPI 1558317784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558317784 NPI number — DR. SHAN K BAGBY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGBY
Provider First Name:
SHAN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1558317784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9275 DOERR RD, BLDG 1221 STE 140
Provider Second Line Business Mailing Address:
HQ, NORTHERN REGION DENTAL COMMAND (ATTN CREDENTIALS)
Provider Business Mailing Address City Name:
FORT BELOIR
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22060-2205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-231-5383
Provider Business Mailing Address Fax Number:
502-624-2966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 GIBNER ROAD SUITE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLISE BARRACKS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-231-5383
Provider Business Practice Location Address Fax Number:
502-624-2966
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  20428 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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