MEDICARE: NICHOLAS WALLACE HATCHER

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	1223G0001X	General Practice Dentistry	D012830	AZ

General Provider Information

NPI Number	:	1164348371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS WALLACE HATCHER

Provider Business Mailing Address
First Line	:	110 ELIZABETH ST
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2117
Country	:	US
Telephone Number	:	304-941-2333
Fax Number	:

Provider Business Practice Location Address
First Line	:	906 W UNIVERSITY AVE STE 100
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-7115
Country	:	US
Telephone Number	:	928-774-7373
Fax Number	:

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

Provider Enumeration Date	:	06/24/2026
Last Update Date	:	06/24/2026

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