Provider Demographics
NPI:1215159942
Name:HAGERTY, ELIZABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:HAGERTY
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 1:813 E ERDMANN RD S
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-8661
Mailing Address - Country:US
Mailing Address - Phone:317-496-9569
Mailing Address - Fax:
Practice Address - Street 1:112 E 10TH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-8202
Practice Address - Country:US
Practice Address - Phone:812-663-2503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010549A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200859770AMedicaid