Provider Demographics
NPI:1588685028
Name:EGAN, RONALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:EGAN
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 1:3712 KADOW ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5450
Mailing Address - Country:US
Mailing Address - Phone:920-684-8033
Mailing Address - Fax:920-684-6360
Practice Address - Street 1:3712 KADOW ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5450
Practice Address - Country:US
Practice Address - Phone:920-684-8033
Practice Address - Fax:920-684-6360
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33700500Medicaid