Provider Demographics
NPI:1912018748
Name:HATHORN, RANDY S (DMD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:HATHORN
Suffix:
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:BASSFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39421-0549
Mailing Address - Country:US
Mailing Address - Phone:601-943-5126
Mailing Address - Fax:601-943-6143
Practice Address - Street 1:218 A GEN ROBERT E BLOUNT DR
Practice Address - Street 2:
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421-0549
Practice Address - Country:US
Practice Address - Phone:601-943-5426
Practice Address - Fax:601-943-6143
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2016 831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060050Medicaid