Provider Demographics
NPI:1932121118
Name:HASKETT, WALLACE GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:GEORGE
Last Name:HASKETT
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 1:707 24TH AVE SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-3987
Mailing Address - Country:US
Mailing Address - Phone:405-364-6064
Mailing Address - Fax:
Practice Address - Street 1:707 24TH AVE SW
Practice Address - Street 2:SUITE 201
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-3987
Practice Address - Country:US
Practice Address - Phone:405-364-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice