Provider Demographics
NPI:1174642375
Name:HAEUSSNER DENTAL GROUP
Entity Type:Organization
Organization Name:HAEUSSNER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:HAEUSSNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-264-2483
Mailing Address - Street 1:1409 KINGSLEY AVE
Mailing Address - Street 2:BLDG. #11
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4562
Mailing Address - Country:US
Mailing Address - Phone:904-264-2483
Mailing Address - Fax:904-264-0474
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:BLDG. #11
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4562
Practice Address - Country:US
Practice Address - Phone:904-264-2483
Practice Address - Fax:904-264-0474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 63841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty