Provider Demographics
NPI:1013069053
Name:HAZELBAKER, DALE R (DDS)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:R
Last Name:HAZELBAKER
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 1:725 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-3615
Mailing Address - Country:US
Mailing Address - Phone:937-325-7031
Mailing Address - Fax:937-322-7339
Practice Address - Street 1:725 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-3615
Practice Address - Country:US
Practice Address - Phone:937-325-7031
Practice Address - Fax:937-322-7339
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12024122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist