Healthcare Provider Details

I. General information

NPI: 1306853718
Provider Name (Legal Business Name): C. EDWARD HAGAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CLIFFORD AVE
SYLVANIA GA
30467-2012
US

IV. Provider business mailing address

114 MORNINGSIDE DR
SYLVANIA GA
30467-8515
US

V. Phone/Fax

Practice location:
  • Phone: 912-564-7107
  • Fax: 912-564-9349
Mailing address:
  • Phone: 912-564-2173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7053
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: