Provider Demographics
NPI:1194043737
Name:HAGEN, TERRY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TERRY
Other - Middle Name:L
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:331 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 E INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2340
Practice Address - Country:US
Practice Address - Phone:719-425-6051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN246591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice