MEDICARE: DR. ERIC MICHAEL HAGEN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019.032150	IL
2	122300000X	Dentist	019.032150	IL

General Provider Information

NPI Number	:	1407415995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC MICHAEL HAGEN DMD

Provider Business Mailing Address
First Line	:	2025 OXNARD DR
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-2514
Country	:	US
Telephone Number	:	708-845-6556
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1213
Country	:	US
Telephone Number	:	773-365-9928
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	09/18/2024

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