Healthcare Provider Details

I. General information

NPI: 1659423606
Provider Name (Legal Business Name): STEVEN J HOAGBURG DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 MAPLECREST RD
FORT WAYNE IN
46835-3838
US

IV. Provider business mailing address

5715 MAPLECREST RD
FORT WAYNE IN
46835-3838
US

V. Phone/Fax

Practice location:
  • Phone: 260-486-4400
  • Fax: 260-486-9387
Mailing address:
  • Phone: 260-486-4400
  • Fax: 260-486-9387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1200-8796
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: