Healthcare Provider Details

I. General information

NPI: 1316879356
Provider Name (Legal Business Name): GAVIN ALEXANDER HAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE FL 6
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

2120 EMERSON AVE S APT 1
MINNEAPOLIS MN
55405-2626
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-6444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberR927
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: