Provider Demographics
NPI:1588123848
Name:HAGAN, BRONWYN PATRICIA (DDS)
Entity type:Individual
Prefix:
First Name:BRONWYN
Middle Name:PATRICIA
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 1:5829 69TH LN
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-2623
Mailing Address - Country:US
Mailing Address - Phone:917-488-6625
Mailing Address - Fax:
Practice Address - Street 1:5829 69TH LN
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2623
Practice Address - Country:US
Practice Address - Phone:718-429-6931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-17
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY061458122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty