Healthcare Provider Details

I. General information

NPI: 1154529071
Provider Name (Legal Business Name): HATHAWAY ROAD DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SOUTH STREET
HOLYOKE MA
04010
US

IV. Provider business mailing address

210 INTERSTATE NORTH PKWY SE STE 300
ATLANTA GA
30339-2233
US

V. Phone/Fax

Practice location:
  • Phone: 770-916-9000
  • Fax: 770-904-5666
Mailing address:
  • Phone: 770-916-9000
  • Fax: 770-904-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21450
License Number StateMA

VIII. Authorized Official

Name: MICHELLE JACOMINO
Title or Position: DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 770-916-5036