Provider Demographics
NPI:1912184409
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:OWNER/PRESIDENT
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:530-265-6656
Mailing Address - Street 1:101 PROVIDENCE MINE RD
Mailing Address - Street 2:SUITE 103-B
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2939
Mailing Address - Country:US
Mailing Address - Phone:530-265-6656
Mailing Address - Fax:
Practice Address - Street 1:101 PROVIDENCE MINE RD
Practice Address - Street 2:SUITE 103-B
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2939
Practice Address - Country:US
Practice Address - Phone:530-265-6656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty