MEDICARE: DR. RICHARD J HAGSTROM 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	122300000X	Dentist	35401	CA

General Provider Information

NPI Number	:	1316057367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD J HAGSTROM DDS

Provider Business Mailing Address
First Line	:	8923 LA MESA BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-4056
Country	:	US
Telephone Number	:	619-465-5252
Fax Number	:	619-462-8222

Provider Business Practice Location Address
First Line	:	8923 LA MESA BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-4056
Country	:	US
Telephone Number	:	619-465-5252
Fax Number	:	619-462-8222

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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