Healthcare Provider Details

I. General information

NPI: 1891845566
Provider Name (Legal Business Name): RANDOLPH J HAYES JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 SAWGRASS VILLAGE CIR
PONTE VEDRA BEACH FL
32082-5032
US

IV. Provider business mailing address

3109 SAWGRASS VILLAGE CIR
PONTE VEDRA BEACH FL
32082-5032
US

V. Phone/Fax

Practice location:
  • Phone: 904-273-9115
  • Fax: 904-273-7447
Mailing address:
  • Phone: 904-273-9115
  • Fax: 904-273-7447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11279
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: