Provider Demographics
NPI:1639295363
Name:HAGOOD, M. JOHNSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:JOHNSON
Last Name:HAGOOD
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 1:2155 PONCE DE LEON CIR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5337
Mailing Address - Country:US
Mailing Address - Phone:772-567-2237
Mailing Address - Fax:772-567-1052
Practice Address - Street 1:2155 PONCE DE LEON CIR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5337
Practice Address - Country:US
Practice Address - Phone:772-567-2237
Practice Address - Fax:772-567-1052
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN156681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice