Provider Demographics
NPI:1760553614
Name:FAGAN, RONALD J (DDS)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:J
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 1:10662 HALLS RIVER RD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34448
Mailing Address - Country:US
Mailing Address - Phone:352-621-3031
Mailing Address - Fax:
Practice Address - Street 1:1128 W MAIN ST
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34450
Practice Address - Country:US
Practice Address - Phone:352-344-2275
Practice Address - Fax:352-344-1416
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN119691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice