Healthcare Provider Details

I. General information

NPI: 1366634016
Provider Name (Legal Business Name): HAGEN DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 LANGER AVE N
CASSELTON ND
58012-3324
US

IV. Provider business mailing address

PO BOX 520
CASSELTON ND
58012-0520
US

V. Phone/Fax

Practice location:
  • Phone: 701-347-5345
  • Fax: 701-347-5346
Mailing address:
  • Phone: 701-347-5345
  • Fax: 701-347-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2014
License Number StateND

VIII. Authorized Official

Name: DR. JESSE P HAGEN
Title or Position: OWNER
Credential: DDS
Phone: 701-347-5345