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General NPI Number Information
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NPI Number | 1225625791
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Entity Type | Organization
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Legal Business Name | HAGE FOUNDATION INC
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Dates
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Enumeration Date | 12/30/2020
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Last Update Date | 06/15/2021
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Provider Practice Location Address
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Address Line | 217 E CHERRY AVE
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City | JONESBORO
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State | AR
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Zip | 72401-3372
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Country | US
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Telephone | 870-897-9465
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Fax |
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Provider Business Mailing Address
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Address Line | 1620 HILLSIDE DR
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City | JONESBORO
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State | AR
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Zip | 72401-5006
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Country | US
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Telephone | 870-897-9465
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CLEMMISA HARRIS
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Credential | DMD
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Telephone | 870-897-9465
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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