Provider Demographics
NPI:1972985794
Name:HAITHCOCK, DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:HAITHCOCK
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 1:29 CLIFFHANGER POINTE SW
Mailing Address - Street 2:
Mailing Address - City:EUHARLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-6079
Mailing Address - Country:US
Mailing Address - Phone:404-408-5125
Mailing Address - Fax:
Practice Address - Street 1:6304 OLD HIGHWAY 5 STE 100
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2500
Practice Address - Country:US
Practice Address - Phone:770-924-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0150131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice