Provider Demographics
NPI:1528242351
Name:RANDY S. HATHORN D.M.D
Entity type:Organization
Organization Name:RANDY S. HATHORN D.M.D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HATHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-943-5126
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:BASSFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39421-0549
Mailing Address - Country:US
Mailing Address - Phone:601-943-5126
Mailing Address - Fax:601-943-6143
Practice Address - Street 1:218 GEN ROBERT E BLOUNT
Practice Address - Street 2:A
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421-0549
Practice Address - Country:US
Practice Address - Phone:601-943-5126
Practice Address - Fax:601-943-6143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3361-05122300000X
MS2016-83122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03556870Medicaid