Healthcare Provider Details

I. General information

NPI: 1730216094
Provider Name (Legal Business Name): CRYSTAL C HAGAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 CAPP HARLAN ROAD
TOMPKINSVILLE KY
42167-0188
US

IV. Provider business mailing address

PO BOX 188 449 CAPP HARLAN ROAD
TOMPKINSVILLE KY
42167-0188
US

V. Phone/Fax

Practice location:
  • Phone: 270-487-0017
  • Fax:
Mailing address:
  • Phone: 270-487-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6768
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: