Provider Demographics
NPI:1154765576
Name:HAGAN, BRANDON JERROD (DMD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JERROD
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 1:110 IRVING ST NW
Mailing Address - Street 2:DEPARTMENT OF ORTHODONTICS
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-3017
Mailing Address - Country:US
Mailing Address - Phone:202-877-5380
Mailing Address - Fax:202-877-8439
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:DEPARTMENT OF ORTHODONTICS
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-3017
Practice Address - Country:US
Practice Address - Phone:202-877-5380
Practice Address - Fax:202-877-8439
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program