MEDICARE: MYRON HAMPTON JR. DDS

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	390200000X	Student in an Organized Health Care Education/Training Program		MI
2	1223G0001X	General Practice Dentistry	2901600991	MI

General Provider Information

NPI Number	:	1104495597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRON HAMPTON JR. DDS

Provider Business Mailing Address
First Line	:	3767 28TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1873
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3767 28TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1873
Country	:	US
Telephone Number	:	616-233-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2021
Last Update Date	:	08/03/2021

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