Basic Information
| Provider Information | |||||||||
| NPI: | 1518986942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | HAZEL | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 STANLEY RD | ||||||||
| Address2: | DENTAC SUITE 200J | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782347529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102952743 | ||||||||
| FaxNumber: | 2102952602 | ||||||||
| Practice Location | |||||||||
| Address1: | 4519 WOODRUFF RD STE 10 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319046091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608001 | ||||||||
| FaxNumber: | 7066608002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 122300000X | 11586 | TX | N | Dental Providers | Dentist | 1223G0001X | DN008444 | GA | Y | Dental Providers | Dentist | General Practice |
No ID Information.