MEDICARE: HATTIE WILLARD 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	1223G0001X	General Practice Dentistry	2018017584	MO

General Provider Information

NPI Number	:	1699332718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HATTIE WILLARD DDS

Provider Business Mailing Address
First Line	:	7558 CABOODLE WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-5503
Country	:	US
Telephone Number	:	816-616-0383
Fax Number	:

Provider Business Practice Location Address
First Line	:	3347 NEW CENTER PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-2880
Country	:	US
Telephone Number	:	719-694-7576
Fax Number	:

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

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	12/19/2023

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