Provider Demographics
NPI:1497847354
Name:HAKALA, ROY VERNON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:VERNON
Last Name:HAKALA
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 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 143N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:651-642-1013
Mailing Address - Fax:651-642-0947
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 143N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-642-1013
Practice Address - Fax:651-642-0947
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33662100Medicaid
MN1491470OtherTAX ID #
MND8171OtherMINNESOTA DENTAL LICENSE
MND8171OtherMINNESOTA DENTAL LICENSE
MN6257230001Medicare NSC