Provider Demographics
NPI:1790730406
Name:HACKENBERGER, JOHN MASON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MASON
Last Name:HACKENBERGER
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 1:29425 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2203
Mailing Address - Country:US
Mailing Address - Phone:586-755-9340
Mailing Address - Fax:586-755-9341
Practice Address - Street 1:29427 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2203
Practice Address - Country:US
Practice Address - Phone:586-755-9340
Practice Address - Fax:586-755-1081
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010162371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970E07680OtherBLUE CROSS PIN
MI970E07680OtherBLUE CROSS PIN
MI0E0768005Medicare ID - Type Unspecified