MEDICARE: DR. JONATHAN PATRICK HALE 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	DN 21405	FL
2	1223G0001X	General Practice Dentistry	12012803A	IN

General Provider Information

NPI Number	:	1063895670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN PATRICK HALE DDS

Provider Business Mailing Address
First Line	:	4116 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6977
Country	:	US
Telephone Number	:	260-482-3759
Fax Number	:	260-482-3750

Provider Business Practice Location Address
First Line	:	4116 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6977
Country	:	US
Telephone Number	:	260-482-3759
Fax Number	:	260-482-3750

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

Provider Enumeration Date	:	06/30/2015
Last Update Date	:	05/19/2025

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