Healthcare Provider Details

I. General information

NPI: 1316139512
Provider Name (Legal Business Name): CRAIG THEODORE HADGIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 SAINT JOHNS MEDICAL PARK DR
SAINT AUGUSTINE FL
32086-5299
US

IV. Provider business mailing address

22 SAINT JOHNS MEDICAL PARK DR
SAINT AUGUSTINE FL
32086-5299
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-6453
  • Fax:
Mailing address:
  • Phone: 904-797-6453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN18047
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901019608
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: