Healthcare Provider Details

I. General information

NPI: 1164348371
Provider Name (Legal Business Name): NICHOLAS WALLACE HATCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 W UNIVERSITY AVE STE 100
FLAGSTAFF AZ
86001-7115
US

IV. Provider business mailing address

110 ELIZABETH ST
CHARLESTON WV
25311-2117
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-7373
  • Fax:
Mailing address:
  • Phone: 304-941-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012830
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: