Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 07645 | IA |
NPI | 1043360969 |
---|---|
Provider Name | Mr. Jeff A Hagan |
First Address | West Des Moines, IA 50266-1315 |
Second Address | West Des Moines, IA 50266-1315 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2007 |
Last Update Date | 08/07/2007 |