Provider Demographics
NPI:1194861765
Name:EAGAN ORTHODONTICS PC
Entity Type:Organization
Organization Name:EAGAN ORTHODONTICS PC
Other - Org Name:EAGAN FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:EAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-569-8770
Mailing Address - Street 1:17600 W 12 MILE ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1910
Mailing Address - Country:US
Mailing Address - Phone:248-569-8770
Mailing Address - Fax:248-569-2476
Practice Address - Street 1:17600 W 12 MILE ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1910
Practice Address - Country:US
Practice Address - Phone:248-569-8770
Practice Address - Fax:248-569-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty