Healthcare Provider Details

I. General information

NPI: 1407415995
Provider Name (Legal Business Name): ERIC MICHAEL HAGEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 N CLARK ST
CHICAGO IL
60640-1213
US

IV. Provider business mailing address

2025 OXNARD DR
DOWNERS GROVE IL
60516-2514
US

V. Phone/Fax

Practice location:
  • Phone: 773-365-9928
  • Fax:
Mailing address:
  • Phone: 708-845-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032150
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.032150
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: