Provider Demographics
NPI:1568635183
Name:L. RHETT FAGG, D.D.S., M.S.D., PC
Entity Type:Organization
Organization Name:L. RHETT FAGG, D.D.S., M.S.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BECHINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-879-4559
Mailing Address - Street 1:211 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3364
Mailing Address - Country:US
Mailing Address - Phone:219-879-4559
Mailing Address - Fax:219-879-4559
Practice Address - Street 1:211 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3364
Practice Address - Country:US
Practice Address - Phone:219-879-4559
Practice Address - Fax:219-879-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007148A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200356670AMedicaid