Provider Demographics
NPI:1093732000
Name:BRIAN R HABER DDS & JOSEPH A ILACQUA DDS PC
Entity Type:Organization
Organization Name:BRIAN R HABER DDS & JOSEPH A ILACQUA DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ILACQUA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-275-0500
Mailing Address - Street 1:2603 DEKALB PIKE
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401
Mailing Address - Country:US
Mailing Address - Phone:610-275-0500
Mailing Address - Fax:610-275-1054
Practice Address - Street 1:2603 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401
Practice Address - Country:US
Practice Address - Phone:610-275-0500
Practice Address - Fax:610-275-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022706L204E00000X
PADS019424L204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T71933Medicare UPIN
085724Medicare ID - Type Unspecified
094462Medicare ID - Type Unspecified
T71912Medicare UPIN