Provider Demographics
NPI:1164519369
Name:WILLIAM J. HAGERTY DDS INC
Entity type:Organization
Organization Name:WILLIAM J. HAGERTY DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NEVADA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ENDICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-837-1888
Mailing Address - Street 1:1024 NORTH BARRON STREET
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320
Mailing Address - Country:US
Mailing Address - Phone:937-456-6228
Mailing Address - Fax:937-456-0150
Practice Address - Street 1:1024 NORTH BARRON STREET
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320
Practice Address - Country:US
Practice Address - Phone:937-456-6228
Practice Address - Fax:937-456-0150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30016938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty