Provider Demographics
NPI:1578741955
Name:MARK J. HAGELE, DDS, INC.
Entity Type:Organization
Organization Name:MARK J. HAGELE, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HAGELE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-838-6560
Mailing Address - Street 1:1380 19TH HOLE DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7713
Mailing Address - Country:US
Mailing Address - Phone:707-838-6560
Mailing Address - Fax:
Practice Address - Street 1:1380 19TH HOLE DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7713
Practice Address - Country:US
Practice Address - Phone:707-838-6560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty