Provider Demographics
NPI:1184701815
Name:FAGUNDES, DAVID KEITH (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KEITH
Last Name:FAGUNDES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:D.
Other - Middle Name:K
Other - Last Name:FAGUNDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD, MS, PC
Mailing Address - Street 1:105 PARKER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-6436
Mailing Address - Country:US
Mailing Address - Phone:706-884-3636
Mailing Address - Fax:706-884-8490
Practice Address - Street 1:105 PARKER DR
Practice Address - Street 2:SUITE A
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-6436
Practice Address - Country:US
Practice Address - Phone:706-884-3636
Practice Address - Fax:706-884-8490
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL45641223E0200X
GA114351223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
971792OtherUNITED CONCORDIA INSURANC