Healthcare Provider Details

I. General information

NPI: 1922127364
Provider Name (Legal Business Name): JEFFREY K. HAW D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N ELM ST
CRESCO IA
52136-1522
US

IV. Provider business mailing address

PO BOX 201
CRESCO IA
52136-0201
US

V. Phone/Fax

Practice location:
  • Phone: 563-547-2312
  • Fax:
Mailing address:
  • Phone: 563-547-2312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7167
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0039503
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: