Provider Demographics
NPI:1457790453
Name:HAMILL, MARY SUZANNE (DH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUZANNE
Last Name:HAMILL
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:300 MAIN STREET
Mailing Address - City:OAK CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:80467-0008
Mailing Address - Country:US
Mailing Address - Phone:970-736-8118
Mailing Address - Fax:970-736-0678
Practice Address - Street 1:300 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:CO
Practice Address - Zip Code:80467-0008
Practice Address - Country:US
Practice Address - Phone:970-736-8118
Practice Address - Fax:970-736-0678
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000903051124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90402260Medicaid