Provider Demographics
NPI:1780668996
Name:HAGEN, KENNETH J JR (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:HAGEN
Suffix:JR
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 1:2811 N 90TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-5707
Mailing Address - Country:US
Mailing Address - Phone:402-391-0459
Mailing Address - Fax:402-384-8888
Practice Address - Street 1:2811 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-5707
Practice Address - Country:US
Practice Address - Phone:402-391-0459
Practice Address - Fax:402-384-8888
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE46461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47063287713Medicaid
NE132485OtherUNITED CONCORDIA ID#
NE5807OtherBCBS PROVIDER ID