Provider Demographics
NPI:1134307416
Name:HATHAWAY, ANTHONY J (DDS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:HATHAWAY
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 1:1333 W LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-2101
Mailing Address - Country:US
Mailing Address - Phone:563-323-9331
Mailing Address - Fax:563-323-1967
Practice Address - Street 1:1333 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-2101
Practice Address - Country:US
Practice Address - Phone:563-323-9331
Practice Address - Fax:563-323-1967
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1057968Medicaid