Provider Demographics
NPI:1376916171
Name:EGAN, IVAN (RDH)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:EGAN
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4781 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7625
Mailing Address - Country:US
Mailing Address - Phone:616-334-3508
Mailing Address - Fax:
Practice Address - Street 1:2700 BAKER ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-733-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL439003124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist