Provider Demographics
NPI:1861590846
Name:HAGEN, EDWARD JR
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:HAGEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SOUTHEAST 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233
Mailing Address - Country:US
Mailing Address - Phone:503-525-9527
Mailing Address - Fax:503-252-4516
Practice Address - Street 1:620 SOUTHEAST 160TH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236
Practice Address - Country:US
Practice Address - Phone:503-252-9527
Practice Address - Fax:503-252-4516
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD3960122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist