Provider Demographics
NPI:1396351243
Name:MAGNUSON, HAAKEN REED (DMD)
Entity type:Individual
Prefix:DR
First Name:HAAKEN
Middle Name:REED
Last Name:MAGNUSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7727 UPTON OXMOOR LN APT 303
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3424
Mailing Address - Country:US
Mailing Address - Phone:502-377-4683
Mailing Address - Fax:
Practice Address - Street 1:4600 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-3530
Practice Address - Country:US
Practice Address - Phone:502-499-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10524122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist