Provider Demographics
NPI:1154674232
Name:JACOB M BAGLEY
Entity Type:Organization
Organization Name:JACOB M BAGLEY
Other - Org Name:BAGLEY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-358-2626
Mailing Address - Street 1:508 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-2178
Mailing Address - Country:US
Mailing Address - Phone:856-358-2626
Mailing Address - Fax:
Practice Address - Street 1:508 FRONT ST
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2178
Practice Address - Country:US
Practice Address - Phone:856-358-2626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty