Provider Demographics
NPI:1245800333
Name:HACKMAN, KENDRA JEAN DESIREE (DMD)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:JEAN DESIREE
Last Name:HACKMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 S LAKE DR UNIT 7
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5217
Mailing Address - Country:US
Mailing Address - Phone:617-697-7161
Mailing Address - Fax:
Practice Address - Street 1:2901 BROOKS ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7703
Practice Address - Country:US
Practice Address - Phone:406-541-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002640-151223G0001X
MT259071223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program