=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780452052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEIDI K. HAUSAUER, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2023
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3203 CASTRO VALLEY BLVD
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-538-3334
-----------------------------------------------------
Fax | 510-538-4116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3203 CASTRO VALLEY BLVD
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-538-3334
-----------------------------------------------------
Fax | 510-538-4116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HEIDI KATHRYN HAUSAUER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 510-538-3334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------