Provider Demographics
NPI:1497745012
Name:HABERKORN, ROBERT M (DDS,MBA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:HABERKORN
Suffix:
Gender:M
Credentials:DDS,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 ALLENDALE-FAIRFAX HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827
Mailing Address - Country:US
Mailing Address - Phone:803-632-3301
Mailing Address - Fax:
Practice Address - Street 1:1987 ALLENDALE-FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827
Practice Address - Country:US
Practice Address - Phone:803-632-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020317561223G0001X
SCSC69511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice