Provider Demographics
NPI:1306853718
Name:HAGAN, C. EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:EDWARD
Last Name:HAGAN
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 1:114 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:GA
Mailing Address - Zip Code:30467-8515
Mailing Address - Country:US
Mailing Address - Phone:912-564-2173
Mailing Address - Fax:
Practice Address - Street 1:112 CLIFFORD AVE
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-2012
Practice Address - Country:US
Practice Address - Phone:912-564-7107
Practice Address - Fax:912-564-9349
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00046373AMedicaid