Provider Demographics
NPI:1700976719
Name:BAGNOLI, MICHAEL LEONARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEONARD
Last Name:BAGNOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 REDWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:765-446-9567
Practice Address - Street 1:2020 UNION STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-446-8808
Practice Address - Fax:765-446-9567
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008541A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN807910AMedicare ID - Type Unspecified