Healthcare Provider Details

I. General information

NPI: 1780293480
Provider Name (Legal Business Name): BRIAN JEFFREY HOAGBURG DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9409 ILLINOIS RD
FORT WAYNE IN
46804-5795
US

IV. Provider business mailing address

9409 ILLINOIS RD
FORT WAYNE IN
46804-5795
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12013167A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: