Provider Demographics
NPI:1063649549
Name:DISTINCTIVE DENTISTRY
Entity Type:Organization
Organization Name:DISTINCTIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:E
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-949-1420
Mailing Address - Street 1:595 PUTNAM PIKE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02828-2137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 PUTNAM PIKE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-2137
Practice Address - Country:US
Practice Address - Phone:401-949-1420
Practice Address - Fax:401-949-5494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDI83209Medicaid
RIDI83209Medicaid