Provider Demographics
NPI:1639898307
Name:HAGBERG, MELISSA CAROL (RDH)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAROL
Last Name:HAGBERG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6944 COUNTY ROAD 127
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-7214
Mailing Address - Country:US
Mailing Address - Phone:218-270-0324
Mailing Address - Fax:
Practice Address - Street 1:7674 DESIGN RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8439
Practice Address - Country:US
Practice Address - Phone:218-828-4816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH7582124Q00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist