Provider Demographics
NPI:1215059837
Name:HAAG, GORDON ELWOOD JR (DDS)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ELWOOD
Last Name:HAAG
Suffix:JR
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 1:301 W BASTANCHURY RD
Mailing Address - Street 2:STE.#260
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3419
Mailing Address - Country:US
Mailing Address - Phone:714-879-4910
Mailing Address - Fax:714-879-5563
Practice Address - Street 1:301 W BASTANCHURY RD
Practice Address - Street 2:STE.#260
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3419
Practice Address - Country:US
Practice Address - Phone:714-879-4910
Practice Address - Fax:714-879-5563
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice