Provider Demographics
NPI:1639725732
Name:FAGEL, JOHN JEROME (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JEROME
Last Name:FAGEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 TWILIGHT DR
Mailing Address - Street 2:
Mailing Address - City:CRESCENT SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-4488
Mailing Address - Country:US
Mailing Address - Phone:859-496-4647
Mailing Address - Fax:
Practice Address - Street 1:07 CHOOS GAI DR
Practice Address - Street 2:
Practice Address - City:TOHATCHI
Practice Address - State:NM
Practice Address - Zip Code:87325
Practice Address - Country:US
Practice Address - Phone:505-733-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice