Provider Demographics
NPI:1306067400
Name:HAZELTON, THOMAS I (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:I
Last Name:HAZELTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:2382 BLACK RIVER ST
Mailing Address - City:DECKERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48427
Mailing Address - Country:US
Mailing Address - Phone:810-376-2395
Mailing Address - Fax:810-376-2305
Practice Address - Street 1:2382 BLACK RIVER ST
Practice Address - Street 2:
Practice Address - City:DECKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48427
Practice Address - Country:US
Practice Address - Phone:810-376-2395
Practice Address - Fax:810-376-2305
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI142091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice