MEDICARE: DR. DEREK E HATHAWAY DMD

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	DS035454	PA
2	122300000X	Dentist	DEN02968	RI

General Provider Information

NPI Number	:	1417911330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEREK E HATHAWAY DMD

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

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	11/13/2009

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