Provider Demographics
NPI:1083888036
Name:RANDY FAGAN DDS, PC
Entity Type:Organization
Organization Name:RANDY FAGAN DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-455-6406
Mailing Address - Street 1:2221 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6726
Mailing Address - Country:US
Mailing Address - Phone:918-455-6406
Mailing Address - Fax:918-455-1856
Practice Address - Street 1:2221 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6726
Practice Address - Country:US
Practice Address - Phone:918-455-6406
Practice Address - Fax:918-455-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty