Provider Demographics
NPI:1265589030
Name:HAGE, LAURENCE MATTHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:MATTHEW
Last Name:HAGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2901
Mailing Address - Country:US
Mailing Address - Phone:228-864-3416
Mailing Address - Fax:228-864-5437
Practice Address - Street 1:400 PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-2901
Practice Address - Country:US
Practice Address - Phone:228-864-3416
Practice Address - Fax:228-864-5437
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3271-031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06456021Medicaid