Provider Demographics
NPI:1609880772
Name:HYATT, KEVIN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:HYATT
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 1:301 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5736
Mailing Address - Country:US
Mailing Address - Phone:440-323-2523
Mailing Address - Fax:440-323-2690
Practice Address - Street 1:301 EAST AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5736
Practice Address - Country:US
Practice Address - Phone:440-323-2523
Practice Address - Fax:440-323-2690
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30. 017356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0542943Medicaid