=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225196363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID J. HAGSTROM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2112 VIKING DR NW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-288-1744
-----------------------------------------------------
Fax | 507-292-5776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2112 VIKING DR NW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-288-1744
-----------------------------------------------------
Fax | 507-292-5776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DAVID JEROME HAGSTROM
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 507-288-1744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D11449
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------