Provider Demographics
NPI:1326478165
Name:HABERMAN, GLEN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:D
Last Name:HABERMAN
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 1:141 WISCONSIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186
Mailing Address - Country:US
Mailing Address - Phone:262-547-5637
Mailing Address - Fax:
Practice Address - Street 1:141 WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186
Practice Address - Country:US
Practice Address - Phone:262-547-5637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist