Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 105037 | CO |
NPI | 1003028002 |
---|---|
Provider Name | Dr. Kent T. Haynes |
First Address | Durango, CO 81301-8530 |
Second Address | Durango, CO 81301-8530 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2007 |
Last Update Date | 08/07/2007 |