Provider Demographics
NPI:1518946755
Name:HAACK, ROBERT CHARLES (DDS)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CHARLES
Last Name:HAACK
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 1:6809 CASCADE RD SE STE F
Mailing Address - Street 2:SUITE E
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6895
Mailing Address - Country:US
Mailing Address - Phone:616-942-9040
Mailing Address - Fax:616-837-9705
Practice Address - Street 1:6809 CASCADE RD SE STE F
Practice Address - Street 2:SUITE E
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6895
Practice Address - Country:US
Practice Address - Phone:616-942-9040
Practice Address - Fax:616-837-9705
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010104281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D104280OtherBLUE CROSS / BLUE SHIELD