Provider Demographics
NPI:1518089960
Name:ROBERT D. HAZEN D.D.S., PC
Entity Type:Organization
Organization Name:ROBERT D. HAZEN D.D.S., PC
Other - Org Name:ROBERT D. HAZEN D.D.S., P.C
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:HAZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-295-5586
Mailing Address - Street 1:460 S 400 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4975
Mailing Address - Country:US
Mailing Address - Phone:801-295-5586
Mailing Address - Fax:801-292-5342
Practice Address - Street 1:460 S 400 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4975
Practice Address - Country:US
Practice Address - Phone:801-295-5586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT130257-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT130257-9921OtherSTATE LICENSE INFORMATION