=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679676134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAYES DENTAL ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 07/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3073 GEORGE WASHINGTON HWY
-----------------------------------------------------
City | HAYES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-642-2212
-----------------------------------------------------
Fax | 804-642-9026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 665
-----------------------------------------------------
City | HAYES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-642-2212
-----------------------------------------------------
Fax | 804-642-9026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. ROBERT W. GEORGE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 804-642-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401411190
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0401008284
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6140
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------