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General NPI Number Information
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NPI Number | 1457621260
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Entity Type | Organization
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Legal Business Name | GORDON E HAAG, JR, DDS, INC
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Dates
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Enumeration Date | 01/10/2012
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Last Update Date | 01/10/2012
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Provider Practice Location Address
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Address Line | 301 W BASTANCHURY RD SUITE 260
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City | FULLERTON
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State | CA
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Zip | 92835-3419
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Country | US
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Telephone | 714-879-4910
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Fax | 714-879-5563
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Provider Business Mailing Address
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Address Line | 301 W BASTANCHURY RD SUITE 260
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City | FULLERTON
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State | CA
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Zip | 92835-3419
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Country | US
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Telephone | 714-879-4910
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Fax | 714-879-5563
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Authorized Official
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Title or Position | OWNER
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Name | GORDON E HAAG JR.
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Credential | DDS
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Telephone | 714-879-4910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 272952
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License Number State | CA
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