Provider Demographics
NPI:1588612790
Name:FAGAN, MARK W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:FAGAN
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 1:120 MILL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-9744
Mailing Address - Country:US
Mailing Address - Phone:915-841-8661
Mailing Address - Fax:
Practice Address - Street 1:10205 N RIVA RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5457
Practice Address - Country:US
Practice Address - Phone:315-772-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD119641223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics