Provider Demographics
NPI:1730216094
Name:HAGAN, CRYSTAL C (DMD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:C
Last Name:HAGAN
Suffix:
Gender:F
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:PO BOX 188
Mailing Address - Street 2:449 CAPP HARLAN ROAD
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-0188
Mailing Address - Country:US
Mailing Address - Phone:270-487-0017
Mailing Address - Fax:
Practice Address - Street 1:449 CAPP HARLAN ROAD
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-0188
Practice Address - Country:US
Practice Address - Phone:270-487-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6768122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
829583OtherUNITED CONCORDIA
TN0176688OtherBLUE CROSS BLUE SHIELD