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General NPI Number Information
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NPI Number | 1891934550
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Entity Type | Organization
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Legal Business Name | HACKNEY FAMILY DENTISTRY
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Dates
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Enumeration Date | 02/19/2009
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Last Update Date | 02/19/2009
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Provider Practice Location Address
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Address Line | 1051 SE STATE ROUTE 3
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City | SHELTON
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State | WA
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Zip | 98584-7117
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Country | US
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Telephone | 360-426-1676
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Fax | 360-427-4303
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Provider Business Mailing Address
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Address Line | PO BOX 398
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City | SHELTON
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State | WA
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Zip | 98584-0398
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Country | US
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Telephone | 360-426-1676
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Fax | 360-427-4304
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Authorized Official
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Title or Position | PARTNER/DENTIST
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Name | DR. KYLE HOUSTON HACKNEY
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Credential | DDS
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Telephone | 360-426-1676
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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 | DE60035243
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License Number State | WA
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