Provider Demographics
NPI:1013016518
Name:HACK, RICHARD A (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:HACK
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 1:2101 E CALUMET ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4743
Mailing Address - Country:US
Mailing Address - Phone:920-731-2773
Mailing Address - Fax:920-731-6878
Practice Address - Street 1:2101 E CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4743
Practice Address - Country:US
Practice Address - Phone:920-731-2773
Practice Address - Fax:920-731-6878
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001270G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice