MEDICARE: DISTINCTIVE DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063649549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISTINCTIVE DENTISTRY

Provider Business Mailing Address
First Line	:	595 PUTNAM PIKE
Second Line	:
City	:	GREENVILLE
State	:	RI
Zip	:	02828-2137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	595 PUTNAM PIKE
Second Line	:
City	:	GREENVILLE
State	:	RI
Zip	:	02828-2137
Country	:	US
Telephone Number	:	401-949-1420
Fax Number	:	401-949-5494

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DEREK E HATHAWAY
Credential	:	DMD
Telephone Number	:	401-949-1420

Provider Enumeration Date	:	06/11/2009
Last Update Date	:	05/26/2011

Similar Medicare Providers

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Practice Location Address:

595 PUTNAM PIKE
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02828-2137

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1295867661 — TOWN OF SMITHFIELD
Practice Location Address:

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02828-2137

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1164809273 — JEAN RESNEVIC, DMD, LLC
Practice Location Address:

595 PUTNAM PIKE
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02828-2137

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1255850459 — MRS. CHERRELLE LAMIKA FERGUSON
Practice Location Address:

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1205344918 — RISING ANGELS
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Directions to “DISTINCTIVE DENTISTRY ” Practice Location

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