Provider Demographics
NPI:1417911330
Name:HATHAWAY, DEREK E (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:E
Last Name:HATHAWAY
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 1:595 PUTNAM PIKE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02828-2137
Mailing Address - Country:US
Mailing Address - Phone:401-949-1420
Mailing Address - Fax:
Practice Address - Street 1:595 PUTNAM PIKE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-2137
Practice Address - Country:US
Practice Address - Phone:401-949-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035454122300000X
RIDEN02968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist