Provider Demographics
NPI:1376880781
Name:HASENFELT, BROOKE AMBER
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:AMBER
Last Name:HASENFELT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:AMBER
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2117 LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3292
Mailing Address - Country:US
Mailing Address - Phone:262-385-1628
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8161
Practice Address - Country:US
Practice Address - Phone:252-737-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC150907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist