Basic Information
| Provider Information | |||||||||
| NPI: | 1558317784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGBY | ||||||||
| FirstName: | SHAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9275 DOERR RD, BLDG 1221 STE 140 | ||||||||
| Address2: | HQ, NORTHERN REGION DENTAL COMMAND (ATTN CREDENTIALS) | ||||||||
| City: | FORT BELOIR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220602205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712315383 | ||||||||
| FaxNumber: | 5026242966 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 GIBNER ROAD SUITE 2 | ||||||||
| Address2: | |||||||||
| City: | CARLISE BARRACKS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712315383 | ||||||||
| FaxNumber: | 5026242966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 20428 | TX | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.