Provider Demographics
NPI:1396223087
Name:HIAM, DEREK WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:WILLIAM
Last Name:HIAM
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:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-0044
Mailing Address - Country:US
Mailing Address - Phone:701-308-0151
Mailing Address - Fax:
Practice Address - Street 1:513 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4145
Practice Address - Country:US
Practice Address - Phone:701-308-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND23501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice