Provider Demographics
NPI:1033109723
Name:HAUCK, TERRANCE LEO (MD,DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:LEO
Last Name:HAUCK
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 S HOGAN CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-8105
Mailing Address - Country:US
Mailing Address - Phone:509-448-8790
Mailing Address - Fax:
Practice Address - Street 1:101 W CASCADE WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6003
Practice Address - Country:US
Practice Address - Phone:509-468-1535
Practice Address - Fax:509-467-6372
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA586451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5034061Medicaid
WA58645OtherLICENSE
WA153400OtherL&I
WA153400OtherL&I