Provider Demographics
NPI:1518986991
Name:HASBROUCK, JOHN G (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:HASBROUCK
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 1:9640 FEATHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458
Mailing Address - Country:US
Mailing Address - Phone:937-885-3522
Mailing Address - Fax:
Practice Address - Street 1:6651 CENTERVILLE BUSINESS PKWY
Practice Address - Street 2:
Practice Address - City:CENTERVILLE FINANCE
Practice Address - State:OH
Practice Address - Zip Code:45459-2689
Practice Address - Country:US
Practice Address - Phone:937-312-0044
Practice Address - Fax:937-312-0088
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH157591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice