Provider Demographics
NPI:1558816439
Name:BAGLEY, JENNICA M (RDH)
Entity Type:Individual
Prefix:
First Name:JENNICA
Middle Name:M
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 SE TECH CENTER DR
Mailing Address - Street 2:BLDG. 13, SUITE 150
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5512
Mailing Address - Country:US
Mailing Address - Phone:360-892-7107
Mailing Address - Fax:360-852-8945
Practice Address - Street 1:1201 SE TECH CENTER DR
Practice Address - Street 2:BLDG. 13, SUITE 150
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5512
Practice Address - Country:US
Practice Address - Phone:360-892-7107
Practice Address - Fax:360-852-8945
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH 6506124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist