Provider Demographics
NPI:1063567279
Name:HAFER, JACK M (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:HAFER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13779 PINECREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-4513
Mailing Address - Country:US
Mailing Address - Phone:727-595-3757
Mailing Address - Fax:
Practice Address - Street 1:2525 PASADENA AVE S
Practice Address - Street 2:STE E
Practice Address - City:PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707
Practice Address - Country:US
Practice Address - Phone:727-360-7063
Practice Address - Fax:727-367-6751
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN5390122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist