| Doctor Name: | DR. LLYNDALL RHETT FAGG |
| NPI Number: | 1093715963 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DDS MSD |
| License Number: | 12007148A |
| Business Practice Address: | 211 Medical Plz Michigan City, IN - 463603364 |
| Business Phone Number: | 2198794559 |
| Business Fax Number: | 2198794559 |
| Mailing Address: | 211 Medical Plz, MICHIGAN CITY |
| State: | IN |
| Postal Code: | 463603364 |
| Phone Number: | 2198794559 |
| Fax Number: | 2198794559 |
| NPI Enumeration Date: | 07/21/2005 |
| NPI Last Update Date: | 09/12/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | 12007148A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |