=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376089904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAZEL MCCAUGHAN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2017
-----------------------------------------------------
Last Update Date | 01/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1149 OLD FANNIN RD #26
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39047-9244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-992-7972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 OAKMONT TRL
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-8718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-605-9552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3063-98
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------