Provider Demographics
NPI:1124306261
Name:HAGAN, TRACY COLE (DMD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:COLE
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 1:7300 GIRARD AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5138
Mailing Address - Country:US
Mailing Address - Phone:858-344-7978
Mailing Address - Fax:
Practice Address - Street 1:7300 GIRARD AVE STE 207
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5138
Practice Address - Country:US
Practice Address - Phone:858-344-7978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA473701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics