Provider Demographics
NPI:1790042323
Name:HAUPT, ANASTASIA MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:MARIE
Last Name:HAUPT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 DAVIS ST UNIT 2011
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-7104
Mailing Address - Country:US
Mailing Address - Phone:208-251-6098
Mailing Address - Fax:
Practice Address - Street 1:807 DAVIS ST UNIT 2011
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-7104
Practice Address - Country:US
Practice Address - Phone:208-251-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190290701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery