Provider Demographics
NPI:1215135280
Name:HAGE FAMILY DENTISTRY
Entity type:Organization
Organization Name:HAGE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:HAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-864-3416
Mailing Address - Street 1:400 PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2901
Mailing Address - Country:US
Mailing Address - Phone:228-864-3416
Mailing Address - Fax:
Practice Address - Street 1:400 PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-2901
Practice Address - Country:US
Practice Address - Phone:228-864-3416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3271-031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty