Provider Demographics
NPI:1891463063
Name:HAGGARD, IAN STORM (DMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:STORM
Last Name:HAGGARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 W MARKET ST STE A
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2456
Mailing Address - Country:US
Mailing Address - Phone:256-232-3415
Mailing Address - Fax:
Practice Address - Street 1:721 W MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2456
Practice Address - Country:US
Practice Address - Phone:256-232-3415
Practice Address - Fax:256-230-2648
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0006969-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice