Provider Demographics
NPI:1952843997
Name:HAKE, LAUREL ANN (RDH)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:ANN
Last Name:HAKE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:ANN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:195 W. 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650
Mailing Address - Country:US
Mailing Address - Phone:707-477-9159
Mailing Address - Fax:
Practice Address - Street 1:195 W 14TH
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-4716
Practice Address - Country:US
Practice Address - Phone:707-477-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.000002391124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist