Provider Demographics
NPI:1568476083
Name:HACKBARTH, MARK DANIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
Last Name:HACKBARTH
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 1:12770 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4628
Mailing Address - Country:US
Mailing Address - Phone:262-782-6311
Mailing Address - Fax:262-782-6770
Practice Address - Street 1:12770 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4628
Practice Address - Country:US
Practice Address - Phone:262-782-6311
Practice Address - Fax:262-782-6770
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist