MEDICARE: DR. CARL HAEDGE III DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D7677	MN

General Provider Information

NPI Number	:	1194713305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARL HAEDGE III DDS

Provider Business Mailing Address
First Line	:	19165 EAGLEVIEW LN
Second Line	:
City	:	PRIOR LAKE
State	:	MN
Zip	:	55372-3801
Country	:	US
Telephone Number	:	952-226-6312
Fax Number	:	651-457-6682

Provider Business Practice Location Address
First Line	:	1525 LIVINGSTON AVE
Second Line	:
City	:	WEST SAINT PAUL
State	:	MN
Zip	:	55118-3411
Country	:	US
Telephone Number	:	651-457-4888
Fax Number	:	651-457-6682

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	07/08/2007

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