Provider Demographics
NPI:1255351664
Name:BAGLEY, WILLIAM ATHERTON (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ATHERTON
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 1:369 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7030
Mailing Address - Country:US
Mailing Address - Phone:207-782-0044
Mailing Address - Fax:207-782-0343
Practice Address - Street 1:369 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7030
Practice Address - Country:US
Practice Address - Phone:207-782-0044
Practice Address - Fax:207-782-0343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME23241223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME106290000Medicaid
ME01-0323907OtherTIN
ME01-0323907OtherTIN
MET31413Medicare ID - Type Unspecified