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General NPI Number Information
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NPI Number | 1295812782
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Entity Type | Organization
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Legal Business Name | HATALA ORTHODONTICS PC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 165 RIVERSIDEDRIVE
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City | JOHNSON CITY
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State | NY
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Zip | 13790
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Country | US
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Telephone | 607-644-9100
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Fax | 607-644-9113
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Provider Business Mailing Address
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Address Line | 165 RIVERSIDE DRIVE
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City | JOHNSON CITY
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State | NY
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Zip | 13790
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Country | US
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Telephone | 607-644-9100
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Fax | 607-644-9113
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Authorized Official
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Title or Position | PRES
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Name | MARK P HATALA
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Credential | DDS
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Telephone | 607-644-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 041662
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License Number State | NY
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