Provider Demographics
NPI:1184294464
Name:BLACK, HAYDEN DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:HAYDEN
Middle Name:DEAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:611 W LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-6243
Mailing Address - Country:US
Mailing Address - Phone:918-284-0164
Mailing Address - Fax:
Practice Address - Street 1:900 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4252
Practice Address - Country:US
Practice Address - Phone:918-652-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist