Provider Demographics
NPI:1679307102
Name:HAGAN, KATIE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:
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 1:236 BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2460 MISSION ST STE 106
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2430
Practice Address - Country:US
Practice Address - Phone:415-849-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1105481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice