Basic Information
| Provider Information | |||||||||
| NPI: | 1265880470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HACKBARTH | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 NASHVILLE PIKE A | ||||||||
| Address2: | |||||||||
| City: | GALLATIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152418022 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 923 NASHVILLE PIKE A | ||||||||
| Address2: | |||||||||
| City: | GALLATIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152418022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | 10500 | TN | Y | Dental Providers | Dentist | General Practice |
No ID Information.