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Provider Information for 1205042736



JAN P FUGAL DDS

Gender: MALE

Individual NPI: 1205042736

Calendar   Last Updated:  2007-07-08
  Certification Date: 

Details

Name Value
NPI 1205042736
Enumeration Date 2007-05-14
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 348 MILTON AVE
BALLSTON SPA, NY 12020-1415
United States

Phone: 518-885-7551 | Fax: 518-885-8060
View Map External Link
Primary Practice Address 348 MILTON AVE
BALLSTON SPA, NY 12020-1415
United States

Phone: 518-885-7551 | Fax: 518-885-8060
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist NY NY052523-1
No 122300000X - Dentist WI 5620-015