Provider Demographics
NPI:1952472029
Name:HATHAWAY, BRADLEY WYATT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WYATT
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 95125
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72190
Mailing Address - Country:US
Mailing Address - Phone:501-626-1830
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:501-626-1830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice