Provider Demographics
NPI:1518986942
Name:HAYNES, HAZEL P (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAZEL
Middle Name:P
Last Name:HAYNES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 STANLEY RD
Mailing Address - Street 2:DENTAC SUITE 200J
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7529
Mailing Address - Country:US
Mailing Address - Phone:210-295-2743
Mailing Address - Fax:210-295-2602
Practice Address - Street 1:4519 WOODRUFF RD STE 10
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6091
Practice Address - Country:US
Practice Address - Phone:706-660-8001
Practice Address - Fax:706-660-8002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11586122300000X
GADN0084441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist