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General NPI Number Information
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NPI Number | 1316426752
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Entity Type | Individual
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Provider Name | BRADLEY JOHN HAGEN
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Gender | Male
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Dates
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Enumeration Date | 08/07/2018
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 814 MAHTOMEDI AVE
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City | MAHTOMEDI
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State | MN
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Zip | 55115-1730
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Country | US
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Telephone | 651-426-0011
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Fax |
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Provider Business Mailing Address
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Address Line | 814 MAHTOMEDI AVE
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City | MAHTOMEDI
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State | MN
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Zip | 55115-1730
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Country | US
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Telephone | 651-426-0011
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401417733
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DEN.00203682
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D15217
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License Number State | MN
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