Healthcare Provider Details

I. General information

NPI: 1174592877
Provider Name (Legal Business Name): DEAN H HATTAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD I-40, EXIT 102
ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5300
  • Fax: 505-552-5811
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number001231
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2106
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: