Provider Demographics
NPI:1871754614
Name:FAGAN, TIMOTHY B (DMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:B
Last Name:FAGAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-0160
Mailing Address - Country:US
Mailing Address - Phone:229-985-4674
Mailing Address - Fax:
Practice Address - Street 1:7 LONG LEAF OFFICE PARK
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6781
Practice Address - Country:US
Practice Address - Phone:229-985-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0111541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice