Healthcare Provider Details

I. General information

NPI: 1790229383
Provider Name (Legal Business Name): HALES DENTAL PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 NE 7TH ST B
GRANTS PASS OR
97526-1654
US

IV. Provider business mailing address

781 NE 7TH ST B
GRANTS PASS OR
97526-1654
US

V. Phone/Fax

Practice location:
  • Phone: 541-474-1100
  • Fax: 541-474-1103
Mailing address:
  • Phone: 541-474-1100
  • Fax: 541-474-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD6777
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberD6777
License Number StateOR

VIII. Authorized Official

Name: DR. JIM B HALES
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 541-474-1100