Healthcare Provider Details

I. General information

NPI: 1790865921
Provider Name (Legal Business Name): JESSE PAUL HAGEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 9TH AVE N
CASSELTON ND
58012-3339
US

IV. Provider business mailing address

PO BOX 520
CASSELTON ND
58012-0520
US

V. Phone/Fax

Practice location:
  • Phone: 701-347-5345
  • Fax: 701-347-4876
Mailing address:
  • Phone: 701-347-5345
  • Fax: 701-347-4876

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:
Title or Position:
Credential:
Phone: