Provider Demographics
NPI:1902032899
Name:BAGLEY DENTAL
Entity Type:Organization
Organization Name:BAGLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-547-1632
Mailing Address - Street 1:1028 W NIXON ST
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5216
Mailing Address - Country:US
Mailing Address - Phone:509-547-1632
Mailing Address - Fax:509-547-6932
Practice Address - Street 1:1028 W NIXON ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5216
Practice Address - Country:US
Practice Address - Phone:509-547-1632
Practice Address - Fax:509-547-6932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAGLEY DENTAL, PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 36571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050414Medicaid