Provider Demographics
NPI:1518249861
Name:HAUCK, NATHAN TODD
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:TODD
Last Name:HAUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 THE VLG UNIT 204
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2605
Mailing Address - Country:US
Mailing Address - Phone:509-961-0536
Mailing Address - Fax:
Practice Address - Street 1:15027 MULBERRY DR
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90604-1528
Practice Address - Country:US
Practice Address - Phone:562-906-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA608541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice