Provider Demographics
NPI:1649612136
Name:HAGOS, SAMUEL TEKESTE (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:TEKESTE
Last Name:HAGOS
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 1:2522 CARRIAGE LN
Mailing Address - Street 2:APT 2A
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-7914
Mailing Address - Country:US
Mailing Address - Phone:301-806-1632
Mailing Address - Fax:
Practice Address - Street 1:13601 OFFICE PL
Practice Address - Street 2:#202
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4213
Practice Address - Country:US
Practice Address - Phone:703-986-0434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414144122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist