Provider Demographics
NPI:1689640666
Name:HAGAN, JEAN MELINDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MELINDA
Last Name:HAGAN
Suffix:
Gender:F
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:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019
Mailing Address - Country:US
Mailing Address - Phone:636-937-5707
Mailing Address - Fax:636-937-6023
Practice Address - Street 1:600B N TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019
Practice Address - Country:US
Practice Address - Phone:636-937-5707
Practice Address - Fax:636-937-6023
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014229122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist