Healthcare Provider Details

I. General information

NPI: 1528075058
Provider Name (Legal Business Name): DAVID CHARLES HAGEDORN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 FAIRFIELD AVE
BELLEVUE KY
41073-1010
US

IV. Provider business mailing address

19 PEBBLE CREEK CIR
FORT THOMAS KY
41075-2159
US

V. Phone/Fax

Practice location:
  • Phone: 859-291-7621
  • Fax: 859-491-3454
Mailing address:
  • Phone: 859-781-3521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4747
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: