Provider Demographics
NPI:1407100712
Name:HAAS, GALEN KENT (DDS)
Entity Type:Individual
Prefix:
First Name:GALEN
Middle Name:KENT
Last Name:HAAS
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 1:1639 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6308
Mailing Address - Country:US
Mailing Address - Phone:208-746-0431
Mailing Address - Fax:208-746-2766
Practice Address - Street 1:1639 23RD AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6308
Practice Address - Country:US
Practice Address - Phone:208-746-0431
Practice Address - Fax:208-746-2766
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66D1553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist