Provider Demographics
NPI:1033804075
Name:FAGAN, BREA (DDS)
Entity type:Individual
Prefix:DR
First Name:BREA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6006 GRENFELL LOOP
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-5343
Mailing Address - Country:US
Mailing Address - Phone:410-251-4932
Mailing Address - Fax:
Practice Address - Street 1:8730 CHERRY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-6212
Practice Address - Country:US
Practice Address - Phone:410-251-4932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty