Provider Demographics
NPI:1477653277
Name:HAFDAHL, RICHARD LESLIE (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LESLIE
Last Name:HAFDAHL
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 1:114 CASCADE ST.
Mailing Address - Street 2:P.O. BOX 387
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0387
Mailing Address - Country:US
Mailing Address - Phone:715-294-2334
Mailing Address - Fax:715-294-2220
Practice Address - Street 1:114 CASCADE ST.
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-0387
Practice Address - Country:US
Practice Address - Phone:715-294-2334
Practice Address - Fax:715-294-2220
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist