Provider Demographics
NPI:1386916534
Name:HAGAN, ELIZABETH ANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
Last Name:HAGAN
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 1:416 WAVERLEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-1718
Mailing Address - Country:US
Mailing Address - Phone:408-656-4000
Mailing Address - Fax:
Practice Address - Street 1:416 WAVERLEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-1718
Practice Address - Country:US
Practice Address - Phone:408-656-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA597681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice