Provider Demographics
NPI:1528139227
Name:HAGEN, KYLE BLAKE (DMD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:BLAKE
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-1715
Mailing Address - Country:US
Mailing Address - Phone:618-259-1400
Mailing Address - Fax:
Practice Address - Street 1:96 S 9TH ST
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-1715
Practice Address - Country:US
Practice Address - Phone:618-259-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice