MEDICARE: DR. JOHN MASON HACKENBERGER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2901016237	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	970E07680	OTHER	MI	BLUE CROSS PIN

General Provider Information

NPI Number	:	1790730406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN MASON HACKENBERGER DDS

Provider Business Mailing Address
First Line	:	29425 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-2203
Country	:	US
Telephone Number	:	586-755-9340
Fax Number	:	586-755-9341

Provider Business Practice Location Address
First Line	:	29427 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-2203
Country	:	US
Telephone Number	:	586-755-9340
Fax Number	:	586-755-1081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/24/2009

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