Provider Demographics
NPI:1457710568
Name:HAZELWOOD, AMY (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:HAZELWOOD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S LAFAYETTE DR
Mailing Address - Street 2:212
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3581
Mailing Address - Country:US
Mailing Address - Phone:618-420-9314
Mailing Address - Fax:
Practice Address - Street 1:535 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2097
Practice Address - Country:US
Practice Address - Phone:260-336-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160007851223G0001X
CODEN.002027561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice