Provider Demographics
NPI:1205043064
Name:HAZEL, DOUGLAS JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:HAZEL
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 1:544 LINCOLN WAY W
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1844
Mailing Address - Country:US
Mailing Address - Phone:574-255-6052
Mailing Address - Fax:
Practice Address - Street 1:544 LINCOLN WAY W
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1844
Practice Address - Country:US
Practice Address - Phone:574-255-6052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006605A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist