=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104435395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAASKEN DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2020
-----------------------------------------------------
Last Update Date | 07/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 FOREST AVE E
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55051-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-679-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 FOREST AVE E
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55051-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-679-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LINNEA M HAASKEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-679-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------