Provider Demographics
NPI:1548836752
Name:HAGEDORN, JOHN PHILLIP (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 YORK AVE OFC 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-6841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1737 YORK AVE OFC 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-6841
Practice Address - Country:US
Practice Address - Phone:212-534-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY062515-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program