Basic Information
Provider Information | |||||||||
NPI: | 1851412738 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAMILTON | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9090 SKILLMAN ST | ||||||||
Address2: | SUITE 200C | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752438259 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143425757 | ||||||||
FaxNumber: | 2143404868 | ||||||||
Practice Location | |||||||||
Address1: | 1111 S IRVING HEIGHTS DR | ||||||||
Address2: |   | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750606261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724453600 | ||||||||
FaxNumber: | 9727851223 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2007 | ||||||||
LastUpdateDate: | 10/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 22734 | TX | Y |   | Dental Providers | Dentist |   | 1223G0001X | 22734 | TX | N |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 1479404-11 | 05 | TX |   | MEDICAID | 1479404-06 | 05 | TX |   | MEDICAID | 1801946-01 | 05 | TX |   | MEDICAID | 1479404-03 | 05 | TX |   | MEDICAID | 1479404-07 | 05 | TX |   | MEDICAID | 1801946-02 | 05 | TX |   | MEDICAID | 1801946-03 | 05 | TX |   | MEDICAID | 1479404-05 | 05 | TX |   | MEDICAID | 1801946-04 | 05 | TX |   | MEDICAID | 1479404-04 | 05 | TX |   | MEDICAID | 1479404-09 | 05 | TX |   | MEDICAID | 1479404-10 | 05 | TX |   | MEDICAID | 1801946-05 | 05 | TX |   | MEDICAID | 1479404-01 | 05 | TX |   | MEDICAID | 1479404-08 | 05 | TX |   | MEDICAID | 1479404-12 | 05 | TX |   | MEDICAID |