Provider Demographics
NPI:1598742082
Name:FAGAN, TANA LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TANA
Middle Name:LEE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:TANA
Other - Middle Name:LEE
Other - Last Name:HOPPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8 POND HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018-9728
Mailing Address - Country:US
Mailing Address - Phone:518-674-2878
Mailing Address - Fax:518-437-5931
Practice Address - Street 1:314 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1708
Practice Address - Country:US
Practice Address - Phone:518-437-5731
Practice Address - Fax:518-437-5931
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY46177122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02071401Medicaid