Provider Demographics
NPI:1891795282
Name:HAYCOCK, PAUL WADLEY (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WADLEY
Last Name:HAYCOCK
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E BROADWAY
Mailing Address - Street 2:#42
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1024
Mailing Address - Country:US
Mailing Address - Phone:480-924-8851
Mailing Address - Fax:
Practice Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4373
Practice Address - Country:US
Practice Address - Phone:480-218-7590
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
AZ17471223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics