Provider Demographics
NPI:1588405682
Name:RAGAN, JEREMEY DANIEL
Entity type:Individual
Prefix:
First Name:JEREMEY
Middle Name:DANIEL
Last Name:RAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1509
Mailing Address - Country:US
Mailing Address - Phone:570-861-9781
Mailing Address - Fax:
Practice Address - Street 1:169 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3603
Practice Address - Country:US
Practice Address - Phone:570-491-0126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA32243972122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist