Provider Demographics
NPI:1851892723
Name:BAGNALL FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:BAGNALL FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BAGNALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-475-3997
Mailing Address - Street 1:16 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3002
Mailing Address - Country:US
Mailing Address - Phone:978-475-3997
Mailing Address - Fax:978-409-6065
Practice Address - Street 1:16 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3002
Practice Address - Country:US
Practice Address - Phone:978-475-3997
Practice Address - Fax:978-409-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18565711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty