Provider Demographics
NPI:1295968832
Name:HAEUSSNER, BRIAN DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:HAEUSSNER
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 1:1409 KINGSLEY AVE
Mailing Address - Street 2:#11
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4562
Mailing Address - Country:US
Mailing Address - Phone:904-264-2483
Mailing Address - Fax:904-264-0474
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:#11
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4562
Practice Address - Country:US
Practice Address - Phone:904-264-2483
Practice Address - Fax:904-264-0474
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 180481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice