Provider Demographics
NPI:1942903331
Name:HAGOOD, KATELYN CHRISTIE (DDS)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:CHRISTIE
Last Name:HAGOOD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8375 ARDMOOR DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-7077
Mailing Address - Country:US
Mailing Address - Phone:734-660-5372
Mailing Address - Fax:
Practice Address - Street 1:1610 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-1613
Practice Address - Country:US
Practice Address - Phone:617-379-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN100000691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program