Provider Demographics
NPI:1043688831
Name:HAYNAM, ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:HAYNAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-5265
Mailing Address - Country:US
Mailing Address - Phone:850-229-1043
Mailing Address - Fax:
Practice Address - Street 1:401 CECIL G COSTIN SR BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1928
Practice Address - Country:US
Practice Address - Phone:850-229-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63516122300000X
FLDN250971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty