Provider Demographics
NPI:1992199764
Name:LAGEMANN, ROY
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:LAGEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 N. WAYTE LANE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701
Mailing Address - Country:US
Mailing Address - Phone:408-309-7082
Mailing Address - Fax:
Practice Address - Street 1:290 N WAYTE LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2124
Practice Address - Country:US
Practice Address - Phone:559-459-3562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist