Provider Demographics
NPI:1164792719
Name:DR. KIMBERLY D. HAUG, PC
Entity Type:Organization
Organization Name:DR. KIMBERLY D. HAUG, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAUG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:618-463-7002
Mailing Address - Street 1:2411 MORNING STAR DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5657
Mailing Address - Country:US
Mailing Address - Phone:618-463-7002
Mailing Address - Fax:618-463-7006
Practice Address - Street 1:2411 MORNING STAR DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5657
Practice Address - Country:US
Practice Address - Phone:618-463-7002
Practice Address - Fax:618-463-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0019081223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty