Provider Demographics
NPI:1689697328
Name:HAGEMANN, PAUL G (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:HAGEMANN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6747 W KIMBALL DR
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534-9054
Mailing Address - Country:US
Mailing Address - Phone:715-561-2817
Mailing Address - Fax:
Practice Address - Street 1:210 5TH AVE N
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1209
Practice Address - Country:US
Practice Address - Phone:715-561-3291
Practice Address - Fax:715-561-4377
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50016701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33413300Medicaid