Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 6091 | KY |
N | 122300000X | Dentist | 7047 | TN |
N | 1223P0700X | Prosthodontist | 6091 | KY |
N | 1223P0700X | Prosthodontist | 7047 | TN |
NPI | 1104927060 |
---|---|
Provider Name | Dr. Charles Lee Hatley |
First Address | Ft Gordon, GA 30905-5660 |
Second Address | Ft Gordon, GA 30905-5660 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 08/07/2007 |