Provider Demographics
NPI:1336160035
Name:HAZLE, DARRELL R (DMD)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:R
Last Name:HAZLE
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 1:2306 RIDGEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-4725
Mailing Address - Country:US
Mailing Address - Phone:918-341-1034
Mailing Address - Fax:
Practice Address - Street 1:2306 RIDGEVIEW LN
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-4725
Practice Address - Country:US
Practice Address - Phone:918-341-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist