Provider Demographics
NPI:1639651052
Name:HAYNES, ANGELA RENAE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RENAE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 FAIRWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019
Mailing Address - Country:US
Mailing Address - Phone:901-326-4600
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE DUNN DENTAL BLDG C 517
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163
Practice Address - Country:US
Practice Address - Phone:901-448-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-01
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDH3447124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist