Provider Demographics
NPI:1447357264
Name:BAGWELL, JANETTE T (DDS)
Entity type:Individual
Prefix:DR
First Name:JANETTE
Middle Name:T
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JANETTE
Other - Middle Name:BAGWELL
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:189 KEYSTONE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8936
Mailing Address - Country:US
Mailing Address - Phone:318-664-5442
Mailing Address - Fax:318-665-4425
Practice Address - Street 1:189 KEYSTONE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8936
Practice Address - Country:US
Practice Address - Phone:318-664-5442
Practice Address - Fax:318-665-4425
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
5545101OtherAETNA
LAG7798OtherBLUE CROSS BLUE SHIELD
LA1840424Medicaid