Provider Demographics
NPI:1639274590
Name:HATZIS, GREGORY P (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
Last Name:HATZIS
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:110 BERGEN ST
Mailing Address - Street 2:RM B854
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2495
Mailing Address - Country:US
Mailing Address - Phone:973-972-2444
Mailing Address - Fax:973-972-3689
Practice Address - Street 1:110 BERGEN ST
Practice Address - Street 2:RM B854
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2495
Practice Address - Country:US
Practice Address - Phone:973-972-2444
Practice Address - Fax:973-972-3689
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL9730204E00000X
TX231721223S0112X
NJ22DI023196001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191226305OtherMEDICAID (DENTAL)