Provider Demographics
NPI:1932307329
Name:HAYATT, SAMUEL
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:HAYATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 LA JOLLA VILLAGE DR
Mailing Address - Street 2:# 105
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9121
Mailing Address - Country:US
Mailing Address - Phone:858-455-7777
Mailing Address - Fax:858-455-7767
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR
Practice Address - Street 2:105
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9121
Practice Address - Country:US
Practice Address - Phone:858-455-7777
Practice Address - Fax:858-455-7767
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55781Medicaid