Healthcare Provider Details

I. General information

NPI: 1831637537
Provider Name (Legal Business Name): HALES DENTAL PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 541-474-1100
  • Fax: 541-471-1103
Mailing address:
  • Phone: 541-474-1100
  • Fax: 541-471-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberD6777
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JIMMIE BOB HALES
Title or Position: OWNER
Credential: DDS
Phone: 541-474-1100