Provider Demographics
NPI:1144243585
Name:HAGSTROM, CARLTON BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARLTON
Middle Name:BRUCE
Last Name:HAGSTROM
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 1:208 S US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1928
Mailing Address - Country:US
Mailing Address - Phone:847-587-5400
Mailing Address - Fax:847-587-5400
Practice Address - Street 1:208 S US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1928
Practice Address - Country:US
Practice Address - Phone:847-587-5400
Practice Address - Fax:847-587-5400
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A158701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice