Provider Demographics
NPI:1154529071
Name:HATHAWAY ROAD DENTAL, PC
Entity type:Organization
Organization Name:HATHAWAY ROAD DENTAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-916-5036
Mailing Address - Street 1:210 INTERSTATE NORTH PKWY SE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2233
Mailing Address - Country:US
Mailing Address - Phone:770-916-9000
Mailing Address - Fax:770-904-5666
Practice Address - Street 1:217 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:04010
Practice Address - Country:US
Practice Address - Phone:770-916-9000
Practice Address - Fax:770-904-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty