Provider Demographics
NPI:1184836991
Name:FAGEN, DEREK TIMOTHY (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:TIMOTHY
Last Name:FAGEN
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 1:1729 CRYSTAL BRIDGES
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-2198
Mailing Address - Country:US
Mailing Address - Phone:210-427-6813
Mailing Address - Fax:
Practice Address - Street 1:3038 WILLIAM HARDEE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-2532
Practice Address - Country:US
Practice Address - Phone:210-427-6813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist