Provider Demographics
NPI:1457464729
Name:HAKE, TERRY H (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:H
Last Name:HAKE
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 JAMESTOWN ROAD
Mailing Address - Street 2:STE 102
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185
Mailing Address - Country:US
Mailing Address - Phone:757-229-4115
Mailing Address - Fax:757-229-8297
Practice Address - Street 1:1761 JAMESTOWN ROAD
Practice Address - Street 2:STE 102
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-229-4115
Practice Address - Fax:757-229-8297
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008049122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10153Medicaid
VA234929OtherANTHEM
PA166891OtherUNITED CONCORDIA CO S INC