Provider Demographics
NPI:1114655909
Name:HACKENBURG, KATHI TAYLOR (RDH)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:TAYLOR
Last Name:HACKENBURG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 PRISON LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:VA
Mailing Address - Zip Code:22974-3761
Mailing Address - Country:US
Mailing Address - Phone:434-422-3519
Mailing Address - Fax:
Practice Address - Street 1:144 PRISON LN
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:VA
Practice Address - Zip Code:22974-3761
Practice Address - Country:US
Practice Address - Phone:434-422-3519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0402207080124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist