Provider Demographics
NPI:1285921825
Name:HAMILTON, BLANE REYNOLDS (DMD)
Entity type:Individual
Prefix:
First Name:BLANE
Middle Name:REYNOLDS
Last Name:HAMILTON
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 1:2000 HIGHWAY 157 N STE 120
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4860
Mailing Address - Country:US
Mailing Address - Phone:817-466-8554
Mailing Address - Fax:
Practice Address - Street 1:1759 BROAD PARK CIR S
Practice Address - Street 2:STE 205
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7833
Practice Address - Country:US
Practice Address - Phone:817-453-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX286541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry