Healthcare Provider Details

I. General information

NPI: 1457341588
Provider Name (Legal Business Name): FRED CARL HAEBERLEIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CALIFORNIA ST SUITE 200
SAN FRANCISCO CA
94109-4586
US

IV. Provider business mailing address

1700 CALIFORNIA ST SUITE 200
SAN FRANCISCO CA
94109-4586
US

V. Phone/Fax

Practice location:
  • Phone: 415-441-7766
  • Fax: 415-441-1919
Mailing address:
  • Phone: 415-441-7766
  • Fax: 415-441-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number25895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: