Provider Demographics
NPI:1629124771
Name:HAZUDA, MICHAEL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:HAZUDA
Suffix:JR
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 1:5301 LIMESTONE RD
Mailing Address - Street 2:SUITE #212
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1250
Mailing Address - Country:US
Mailing Address - Phone:302-239-8230
Mailing Address - Fax:302-239-8249
Practice Address - Street 1:5301 LIMESTONE RD
Practice Address - Street 2:SUITE #212
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1250
Practice Address - Country:US
Practice Address - Phone:302-239-8230
Practice Address - Fax:302-239-8249
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000884908Medicaid