Provider Demographics
NPI:1801922463
Name:FAGAN, MAURICE J III (MS, DMD)
Entity type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:J
Last Name:FAGAN
Suffix:III
Gender:M
Credentials:MS, DMD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:JAMES
Other - Last Name:FAGAN
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MS, DMD
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:404-255-5006
Mailing Address - Fax:404-257-1201
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 140
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1703
Practice Address - Country:US
Practice Address - Phone:404-255-5006
Practice Address - Fax:404-257-1201
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 93401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice