Healthcare Provider Details

I. General information

NPI: 1104017060
Provider Name (Legal Business Name): TERRY H HAKE DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 JAMESTOWN ROAD SUITE 102
WILLIAMSBURG VA
23185
US

IV. Provider business mailing address

1761 JAMESTOWN ROAD SUITE 102
WILLIAMSBURG VA
23185
US

V. Phone/Fax

Practice location:
  • Phone: 757-229-4115
  • Fax: 757-229-8297
Mailing address:
  • Phone: 757-229-4115
  • Fax: 757-229-8297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401008049
License Number StateVA

VIII. Authorized Official

Name: TERRY HENRY HAKE
Title or Position: OWNER ENDODONTIST
Credential: DDS
Phone: 757-229-4115