Provider Demographics
NPI:1306062831
Name:PATRICK V. HAGERTY, DMD, PC
Entity type:Organization
Organization Name:PATRICK V. HAGERTY, DMD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-926-3689
Mailing Address - Street 1:1070 24TH AVE SW
Mailing Address - Street 2:PO BOX 649
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-7539
Mailing Address - Country:US
Mailing Address - Phone:541-926-3689
Mailing Address - Fax:541-928-6088
Practice Address - Street 1:1070 24TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-7539
Practice Address - Country:US
Practice Address - Phone:541-926-3689
Practice Address - Fax:541-928-6088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBH0561072OtherDEA
OR178731Medicare ID - Type UnspecifiedOMAP
ORBH0561072OtherDEA