Basic Information
| Provider Information | |||||||||
| NPI: | 1205322252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HATFIELD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97829 SHOPPING CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974159135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418371664 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976013372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2018 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | D10842 | OR | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X | D10842 | OR | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 4285457 | 01 | OR | UNITED CONCORDIA | OTHER | 170061 | 05 | OR | MEDICAID |