Provider Demographics
NPI:1841823895
Name:HATHORNE, KEVIN (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HATHORNE
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 1:4619 SUNFLOWER RD APT 93
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1457
Mailing Address - Country:US
Mailing Address - Phone:734-649-7231
Mailing Address - Fax:
Practice Address - Street 1:4619 SUNFLOWER RD APT 93
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1457
Practice Address - Country:US
Practice Address - Phone:734-649-7231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12876390200000X
TN11969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program