Healthcare Provider Details

I. General information

NPI: 1952843997
Provider Name (Legal Business Name): LAUREL ANN HAKE R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREL ANN WAGNER

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W 14TH
RIFLE CO
81650-4716
US

IV. Provider business mailing address

195 W. 14TH STREET
RIFLE CO
81650
US

V. Phone/Fax

Practice location:
  • Phone: 707-477-9159
  • Fax:
Mailing address:
  • Phone: 707-477-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.000002391
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: