Provider Demographics
NPI:1093474819
Name:RICHARD A FAGIN DDS A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD A FAGIN DDS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:FAGIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:650-823-9606
Mailing Address - Street 1:235 N SAN MATEO DR STE 600
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2675
Mailing Address - Country:US
Mailing Address - Phone:650-342-0213
Mailing Address - Fax:650-342-0636
Practice Address - Street 1:235 N SAN MATEO DR STE 600
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2675
Practice Address - Country:US
Practice Address - Phone:650-342-0213
Practice Address - Fax:650-342-0636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty