Basic Information
| Provider Information | |||||||||
| NPI: | 1174592877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATTAN | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | 5055525811 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 B VETERANS BLVD | ||||||||
| Address2: | I-40, EXIT 102 | ||||||||
| City: | ACOMA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | 5055525811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 001231 | WA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2106 | AZ | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | H3450 | 05 | NM | MEDICAID |