Provider Demographics
NPI:1134587579
Name:HAMATAJ, ADISA (DDS)
Entity type:Individual
Prefix:
First Name:ADISA
Middle Name:
Last Name:HAMATAJ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6975 E PRINCESS DR APT 3120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4234
Mailing Address - Country:US
Mailing Address - Phone:917-664-5944
Mailing Address - Fax:
Practice Address - Street 1:9915 W MCDOWELL RD # ARE106
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4896
Practice Address - Country:US
Practice Address - Phone:623-907-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013929122300000X
390200000X
AZD0103751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty