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General NPI Number Information
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NPI Number | 1215135280
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Entity Type | Organization
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Legal Business Name | HAGE FAMILY DENTISTRY
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Dates
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Enumeration Date | 07/10/2007
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Last Update Date | 07/10/2007
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Provider Practice Location Address
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Address Line | 400 PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-2901
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Country | US
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Telephone | 228-864-3416
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Fax |
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Provider Business Mailing Address
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Address Line | 400 PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-2901
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Country | US
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Telephone | 228-864-3416
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LAURENCE MATTHEW HAGE
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Credential | D.M.D.
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Telephone | 228-864-3416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3271-03
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License Number State | MS
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