Provider Demographics
NPI:1609096023
Name:FAGUNDES, JULIE R
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:R
Last Name:FAGUNDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 SUPERIOR CT STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6179
Mailing Address - Country:US
Mailing Address - Phone:541-779-6170
Mailing Address - Fax:541-779-0989
Practice Address - Street 1:670 SUPERIOR CT STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6179
Practice Address - Country:US
Practice Address - Phone:541-779-6170
Practice Address - Fax:541-779-0989
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD82031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice