Provider Demographics
NPI:1063727402
Name:FEGAN, CHAD WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:WILLIAM
Last Name:FEGAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 DUNHAM RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2118
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0189
Practice Address - Street 1:24760 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0189
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist