=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407273139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL HAYATT DMD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2014
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1530 HILTON HEAD RD STE 111
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92019-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-441-8000
-----------------------------------------------------
Fax | 619-441-8012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1530 HILTON HEAD RD STE 111
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92019-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-441-8000
-----------------------------------------------------
Fax | 619-441-8012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. MAYRA MARTINEZ
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 619-428-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 55781
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------