Provider Demographics
NPI:1679618938
Name:J GREG HAAG DMD PSC
Entity type:Organization
Organization Name:J GREG HAAG DMD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:HAAG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-825-9616
Mailing Address - Street 1:1250 THORNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431
Mailing Address - Country:US
Mailing Address - Phone:270-825-9616
Mailing Address - Fax:270-825-3901
Practice Address - Street 1:1250 THORNBERRY DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431
Practice Address - Country:US
Practice Address - Phone:270-825-9616
Practice Address - Fax:270-825-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60063377Medicaid
KY60063377Medicaid