Provider Demographics
NPI:1780103895
Name:HAGGERTY DENTAL LLC
Entity type:Organization
Organization Name:HAGGERTY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:HAGGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-268-3384
Mailing Address - Street 1:5124 ZUNI RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2833
Mailing Address - Country:US
Mailing Address - Phone:505-268-3384
Mailing Address - Fax:505-265-5554
Practice Address - Street 1:5124 ZUNI RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2833
Practice Address - Country:US
Practice Address - Phone:505-268-3384
Practice Address - Fax:505-265-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD47011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty