Provider Demographics
NPI:1912297623
Name:TAJ M. HAYNES DMD, PA
Entity type:Organization
Organization Name:TAJ M. HAYNES DMD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAJ
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-979-3436
Mailing Address - Street 1:8455 PIT STOP CT NW
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8249
Mailing Address - Country:US
Mailing Address - Phone:704-979-3436
Mailing Address - Fax:
Practice Address - Street 1:8455 PIT STOP CT NW
Practice Address - Street 2:SUITE 140
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8249
Practice Address - Country:US
Practice Address - Phone:704-979-3436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC88321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty