Basic Information
Provider Information
NPI: 1073005708
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HADDOCK
FirstName: ANDREW
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1440
Address2:  
City: WAUTOMA
State: WI
PostalCode: 549821440
CountryCode: US
TelephoneNumber: 9207875514
FaxNumber: 9207874737
Practice Location
Address1: 207 S UNIVERSITY AVE
Address2:  
City: BEAVER DAM
State: WI
PostalCode: 539162450
CountryCode: US
TelephoneNumber: 9203565012
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/30/2018
LastUpdateDate: 05/30/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X1001807-15WIY Dental ProvidersDentist 

No ID Information.


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