Provider Demographics
NPI:1225625791
Name:HAGE FOUNDATION INC
Entity Type:Organization
Organization Name:HAGE FOUNDATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLEMMISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:870-897-9465
Mailing Address - Street 1:1620 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5006
Mailing Address - Country:US
Mailing Address - Phone:870-897-9465
Mailing Address - Fax:
Practice Address - Street 1:217 E CHERRY AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3372
Practice Address - Country:US
Practice Address - Phone:870-897-9465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty