Provider Demographics
NPI:1629171772
Name:HACKBARTH, JOHN GUSTAV JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GUSTAV
Last Name:HACKBARTH
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:HACKBARTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:825 W ROUND BUNCH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-2436
Mailing Address - Country:US
Mailing Address - Phone:409-735-2401
Mailing Address - Fax:409-735-2404
Practice Address - Street 1:825 W ROUND BUNCH RD
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-2436
Practice Address - Country:US
Practice Address - Phone:409-735-2401
Practice Address - Fax:409-735-2404
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice