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General NPI Number Information
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NPI Number | 1528242351
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Entity Type | Organization
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Legal Business Name | RANDY S. HATHORN D.M.D
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Dates
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Enumeration Date | 12/28/2007
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Last Update Date | 12/28/2007
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Provider Practice Location Address
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Address Line | 218 GEN ROBERT E BLOUNT A
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City | BASSFIELD
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State | MS
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Zip | 39421-0549
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Country | US
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Telephone | 601-943-5126
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Fax | 601-943-6143
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Provider Business Mailing Address
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Address Line | PO BOX 549
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City | BASSFIELD
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State | MS
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Zip | 39421-0549
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Country | US
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Telephone | 601-943-5126
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Fax | 601-943-6143
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Authorized Official
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Title or Position | OWNER
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Name | RANDY S HATHORN
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Credential | D.M.D.
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Telephone | 601-943-5126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3361-05
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2016-83
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License Number State | MS
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