Provider Demographics
NPI:1316431372
Name:HAYCOCK, PARKER
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:
Last Name:HAYCOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13520 TERRACE CREEK DR APT 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5809
Mailing Address - Country:US
Mailing Address - Phone:801-915-6396
Mailing Address - Fax:
Practice Address - Street 1:501 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1701
Practice Address - Country:US
Practice Address - Phone:502-852-5625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist