MEDICARE: DR. RAYMOND G. HATLAND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	120069	IN

General Provider Information

NPI Number	:	1235386764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. RAYMOND G. HATLAND

Provider Business Mailing Address
First Line	:	6202 BROADWAY ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-1837
Country	:	US
Telephone Number	:	317-257-0794
Fax Number	:

Provider Business Practice Location Address
First Line	:	6202 BROADWAY ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-1837
Country	:	US
Telephone Number	:	317-257-0794
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAYMOND GILBERT HATLAND
Credential	:	DDS
Telephone Number	:	317-257-0794

Provider Enumeration Date	:	08/27/2008
Last Update Date	:	08/27/2008

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