=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861590846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. EDWARD HAGEN JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 11/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 SOUTHEAST 160TH AVE SUITE D
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-252-9527
-----------------------------------------------------
Fax | 503-252-4516
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 SOUTHEAST 160TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-525-9527
-----------------------------------------------------
Fax | 503-252-4516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3960
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------