Provider Demographics
NPI:1952528010
Name:HAGAN, ANDREW RAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:RAY
Last Name:HAGAN
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 1:3058 FORT HENRY DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664
Mailing Address - Country:US
Mailing Address - Phone:423-239-8021
Mailing Address - Fax:423-239-6273
Practice Address - Street 1:3058 FORT HENRY DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664
Practice Address - Country:US
Practice Address - Phone:423-239-8021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-00176721223G0001X
TN89251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice