Provider Demographics
NPI:1528075058
Name:HAGEDORN, DAVID CHARLES (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 PEBBLE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-2159
Mailing Address - Country:US
Mailing Address - Phone:859-781-3521
Mailing Address - Fax:
Practice Address - Street 1:340 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073-1010
Practice Address - Country:US
Practice Address - Phone:859-291-7621
Practice Address - Fax:859-491-3454
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice