Basic Information
| Provider Information | |||||||||
| NPI: | 1942840392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASSELQUIST | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7665 US HIGHWAY 2 | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548474690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2020 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | Y | Dental Providers | Dental Hygienist |
No ID Information.