Provider Demographics
NPI:1184781528
Name:HAGEN, JUSTIN LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 HAZELTINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318
Mailing Address - Country:US
Mailing Address - Phone:952-361-0777
Mailing Address - Fax:
Practice Address - Street 1:1150 HAZELTINE BLVD
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1004
Practice Address - Country:US
Practice Address - Phone:952-361-0777
Practice Address - Fax:952-361-6729
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN698845800Medicaid