Provider Demographics
NPI:1386854891
Name:EAGAN, JAY VICTOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:VICTOR
Last Name:EAGAN
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:17600 WEST 12 MILE ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-569-8770
Mailing Address - Fax:248-569-2476
Practice Address - Street 1:17600 WEST 12 MILE ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:248-569-8770
Practice Address - Fax:248-569-2476
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI134401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics