Provider Demographics
NPI:1205042736
Name:FUGAL, JAN P (DDS)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:P
Last Name:FUGAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-1415
Mailing Address - Country:US
Mailing Address - Phone:518-885-7551
Mailing Address - Fax:518-885-8060
Practice Address - Street 1:348 MILTON AVE
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-1415
Practice Address - Country:US
Practice Address - Phone:518-885-7551
Practice Address - Fax:518-885-8060
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY052523-1122300000X
WI5620-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist