Provider Demographics
NPI:1295836880
Name:HACKNEY, JASE R (DMD)
Entity type:Individual
Prefix:DR
First Name:JASE
Middle Name:R
Last Name:HACKNEY
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 1:15229 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1823
Mailing Address - Country:US
Mailing Address - Phone:813-962-3396
Mailing Address - Fax:813-963-7668
Practice Address - Street 1:15229 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1823
Practice Address - Country:US
Practice Address - Phone:813-962-3396
Practice Address - Fax:813-963-7668
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL158301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice