1104017060 NPI number — TERRY H HAKE DDS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104017060 NPI number — TERRY H HAKE DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRY H HAKE DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104017060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1761 JAMESTOWN ROAD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
WILLIAMSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-229-4115
Provider Business Mailing Address Fax Number:
757-229-8297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1761 JAMESTOWN ROAD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-229-4115
Provider Business Practice Location Address Fax Number:
757-229-8297
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAKE
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
HENRY
Authorized Official Title or Position:
OWNER ENDODONTIST
Authorized Official Telephone Number:
757-229-4115

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  0401008049 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 234929 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 166891 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10153 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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