Provider Demographics
NPI:1225196363
Name:DAVID J. HAGSTROM LLC
Entity Type:Organization
Organization Name:DAVID J. HAGSTROM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HAGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-288-1744
Mailing Address - Street 1:2112 VIKING DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3522
Mailing Address - Country:US
Mailing Address - Phone:507-288-1744
Mailing Address - Fax:507-292-5776
Practice Address - Street 1:2112 VIKING DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3522
Practice Address - Country:US
Practice Address - Phone:507-288-1744
Practice Address - Fax:507-292-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN39492MAOtherBLUE CROSS BLUE SHIELD
MN9175780OtherDORAL DENTAL IDENTIFIER
MND11449OtherLICENSE NUMBER
MN1348318OtherTRI CARE ID NUMBER
MN9175780OtherDORAL DENTAL IDENTIFIER