Provider Demographics
NPI:1073040184
Name:HASENFUS FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:HASENFUS FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HASENFUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-622-1711
Mailing Address - Street 1:41 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4910
Mailing Address - Country:US
Mailing Address - Phone:207-622-1711
Mailing Address - Fax:207-626-5893
Practice Address - Street 1:41 FULLER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-4910
Practice Address - Country:US
Practice Address - Phone:207-622-1711
Practice Address - Fax:207-626-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4370261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental