Provider Demographics
NPI:1922264563
Name:HAYNES, SUSAN M
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 ISADOR AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6471
Mailing Address - Country:US
Mailing Address - Phone:928-279-9623
Mailing Address - Fax:
Practice Address - Street 1:2065 AIRWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3656
Practice Address - Country:US
Practice Address - Phone:928-692-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist