Provider Demographics
NPI:1598852048
Name:HATHAWAY ROAD DENTAL, PC
Entity Type:Organization
Organization Name:HATHAWAY ROAD DENTAL, PC
Other - Org Name:CORTLAND DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-916-5036
Mailing Address - Street 1:210 INTERSTATE NORTH PKWY SE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2233
Mailing Address - Country:US
Mailing Address - Phone:770-916-9000
Mailing Address - Fax:678-247-7858
Practice Address - Street 1:2181 WASHINGTON STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2082
Practice Address - Country:US
Practice Address - Phone:617-427-5665
Practice Address - Fax:617-445-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty