Healthcare Provider Details

I. General information

NPI: 1972139764
Provider Name (Legal Business Name): JENNIFER A HATHAWAY DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 BROADMOOR DR
BRYAN TX
77802-5210
US

IV. Provider business mailing address

1719 BROADMOOR DR
BRYAN TX
77802-5210
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-6884
  • Fax: 979-774-3008
Mailing address:
  • Phone: 979-776-6884
  • Fax: 979-774-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEVIE FESTER
Title or Position: PRACTICE MANAGER
Credential: RDA
Phone: 979-776-6884