Provider Demographics
NPI:1285127761
Name:HASTINGS, MYLES JORDAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MYLES
Middle Name:JORDAN
Last Name:HASTINGS
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 1:1017 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4120
Mailing Address - Country:US
Mailing Address - Phone:217-235-0381
Mailing Address - Fax:
Practice Address - Street 1:1017 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4120
Practice Address - Country:US
Practice Address - Phone:217-235-0381
Practice Address - Fax:217-235-0396
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0316051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice