Provider Demographics
NPI:1225130040
Name:HATHORN, PAUL IVAN (DMD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:IVAN
Last Name:HATHORN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HIGHWAY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-4443
Mailing Address - Country:US
Mailing Address - Phone:601-477-5792
Mailing Address - Fax:601-477-5782
Practice Address - Street 1:1101 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-4443
Practice Address - Country:US
Practice Address - Phone:601-477-5792
Practice Address - Fax:601-477-5782
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2342-87122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060323Medicaid