Provider Demographics
NPI:1942521885
Name:HAASKEN, BRYCE WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:WAYNE
Last Name:HAASKEN
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 1:130 FOREST AVE E
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1510
Mailing Address - Country:US
Mailing Address - Phone:320-679-1010
Mailing Address - Fax:320-679-1011
Practice Address - Street 1:130 FOREST AVE E
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1510
Practice Address - Country:US
Practice Address - Phone:320-679-1010
Practice Address - Fax:320-679-1011
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND127921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice