Provider Demographics
NPI:1992835045
Name:BAGLEY, JAMES ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ANDREW
Last Name:BAGLEY
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 1:4904 CONVENTION DR.
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301
Mailing Address - Country:US
Mailing Address - Phone:509-547-1631
Mailing Address - Fax:509-547-3885
Practice Address - Street 1:4904 CONVENTION DR.
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301
Practice Address - Country:US
Practice Address - Phone:509-547-1631
Practice Address - Fax:509-547-3885
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE76841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050422Medicaid