Provider Demographics
NPI:1255851291
Name:HAZLE, HUNTER LAMKIN
Entity Type:Individual
Prefix:
First Name:HUNTER
Middle Name:LAMKIN
Last Name:HAZLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43025 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3012
Mailing Address - Country:US
Mailing Address - Phone:502-774-4401
Mailing Address - Fax:
Practice Address - Street 1:43025 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3012
Practice Address - Country:US
Practice Address - Phone:502-774-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016014551223P0221X
KY99401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901601455OtherMI SPECIALTY LICENSE - PEDIATRIC DENTISTRY
KY9940OtherKY DENTAL LICENSE
MI2901601455OtherMI DENTAL LICENSE