Provider Demographics
NPI:1992149306
Name:HATTAWAY, RICHARD SHAD (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SHAD
Last Name:HATTAWAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHAD
Other - Middle Name:
Other - Last Name:HATTAWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:6452 BROADWAY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043
Mailing Address - Country:US
Mailing Address - Phone:972-226-6945
Mailing Address - Fax:972-226-6608
Practice Address - Street 1:6452 BROADWAY BOULEVARD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043
Practice Address - Country:US
Practice Address - Phone:972-226-6945
Practice Address - Fax:972-226-6608
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0239961223G0001X
TX30158122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice