Provider Demographics
NPI:1891858742
Name:FAGAN, SUSAN MILLIE (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MILLIE
Last Name:FAGAN
Suffix:
Gender:F
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:P.O. BOX 1932
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:810-343-1467
Mailing Address - Fax:
Practice Address - Street 1:2650 WASHBURN WAY
Practice Address - Street 2:SUITE 240
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603
Practice Address - Country:US
Practice Address - Phone:541-363-0201
Practice Address - Fax:810-982-9906
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist