Provider Demographics
NPI:1114916244
Name:HACKER, STEFAN SHANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEFAN
Middle Name:SHANE
Last Name:HACKER
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 1:200 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7006
Mailing Address - Country:US
Mailing Address - Phone:918-787-7900
Mailing Address - Fax:
Practice Address - Street 1:1015 W WASHBOURNE ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-4205
Practice Address - Country:US
Practice Address - Phone:918-253-8696
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist