Provider Demographics
NPI:1790865921
Name:HAGEN, JESSE PAUL (DDS)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:PAUL
Last Name:HAGEN
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:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:CASSELTON
Mailing Address - State:ND
Mailing Address - Zip Code:58012-0520
Mailing Address - Country:US
Mailing Address - Phone:701-347-5345
Mailing Address - Fax:701-347-4876
Practice Address - Street 1:5 9TH AVE N
Practice Address - Street 2:
Practice Address - City:CASSELTON
Practice Address - State:ND
Practice Address - Zip Code:58012-3339
Practice Address - Country:US
Practice Address - Phone:701-347-5345
Practice Address - Fax:701-347-4876
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41435Medicaid