Provider Demographics
NPI:1073005708
Name:HADDOCK, ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:HADDOCK
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 1:636 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550
Mailing Address - Country:US
Mailing Address - Phone:309-263-8317
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:636 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550
Practice Address - Country:US
Practice Address - Phone:309-263-8317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190340151223G0001X
WI1001807-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist