Provider Demographics
NPI:1063969657
Name:HAWKINS, FANTA
Entity type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36014 WRATTEN AVE.
Mailing Address - Street 2:
Mailing Address - City:FT. HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-286-7401
Mailing Address - Fax:
Practice Address - Street 1:36014 WRATTEN AVE.
Practice Address - Street 2:
Practice Address - City:FT. HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-286-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist