Provider Demographics
NPI:1457872368
Name:HATARA, ANDREI
Entity Type:Individual
Prefix:
First Name:ANDREI
Middle Name:
Last Name:HATARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 MACGREGOR DOWNS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BRUNSWICK MEDICAL CENTER PKWY NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-1001
Practice Address - Country:US
Practice Address - Phone:910-253-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151143122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist