Provider Demographics
NPI:1992093801
Name:HAYCOCK, JOHN (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HAYCOCK
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 1:315 SWAINS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-5789
Mailing Address - Country:US
Mailing Address - Phone:706-877-3456
Mailing Address - Fax:
Practice Address - Street 1:112 N PARK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1645
Practice Address - Country:US
Practice Address - Phone:770-460-1527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141711223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics