Provider Demographics
NPI:1962890632
Name:HANAWALT DENTAL CORPORATION
Entity type:Organization
Organization Name:HANAWALT DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:M
Authorized Official - Last Name:HANAWALT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-593-4581
Mailing Address - Street 1:2450 D ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-4416
Mailing Address - Country:US
Mailing Address - Phone:909-593-4581
Mailing Address - Fax:
Practice Address - Street 1:2450 D ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-4416
Practice Address - Country:US
Practice Address - Phone:909-593-4581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty