Provider Demographics
NPI:1407415995
Name:HAGEN, ERIC MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MICHAEL
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 OXNARD DR
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-2514
Mailing Address - Country:US
Mailing Address - Phone:708-845-6556
Mailing Address - Fax:
Practice Address - Street 1:2563 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2051
Practice Address - Country:US
Practice Address - Phone:815-748-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0321501223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice