Provider Demographics
NPI:1245513209
Name:HAYWOOD, KEVIN L SR (RDA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:HAYWOOD
Suffix:SR
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 REGAL ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-7948
Mailing Address - Country:US
Mailing Address - Phone:817-614-0794
Mailing Address - Fax:
Practice Address - Street 1:3740 S UNIVERSITY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-3700
Practice Address - Country:US
Practice Address - Phone:817-614-0794
Practice Address - Fax:817-367-7714
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25953126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant