Provider Demographics
NPI:1275703811
Name:HAAKE FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:HAAKE FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-381-6644
Mailing Address - Street 1:4601 W 109TH ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1318
Mailing Address - Country:US
Mailing Address - Phone:913-381-6644
Mailing Address - Fax:913-381-6646
Practice Address - Street 1:4601 W 109TH ST
Practice Address - Street 2:SUITE 112
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1318
Practice Address - Country:US
Practice Address - Phone:913-381-6644
Practice Address - Fax:913-381-6646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS600891223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty