Provider Demographics
NPI:1306157706
Name:HASTINGS, HAGEN V (DMD)
Entity type:Individual
Prefix:DR
First Name:HAGEN
Middle Name:V
Last Name:HASTINGS
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:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:220 BARTON BLVD
Practice Address - Street 2:UNIT C14
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2742
Practice Address - Country:US
Practice Address - Phone:321-639-5177
Practice Address - Fax:321-639-4927
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN191421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003173400Medicaid