Provider Demographics
NPI:1801278890
Name:HINES, JAMES GARRETT (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GARRETT
Last Name:HINES
Suffix:
Gender:M
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:W3275 WOLF RIVER DRIVE
Mailing Address - Street 2:MENOMINEE TRIBAL CLINIC
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135
Mailing Address - Country:US
Mailing Address - Phone:715-799-3960
Mailing Address - Fax:
Practice Address - Street 1:W3275 WOLF RIVER DRIVE
Practice Address - Street 2:MENOMINEE TRIBAL CLINIC
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135
Practice Address - Country:US
Practice Address - Phone:715-799-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001140-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice