=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295919785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENT A VANHALA DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2007
-----------------------------------------------------
Last Update Date | 12/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 PORTAGE ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-2290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-494-0646
-----------------------------------------------------
Fax | 330-494-9181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 PORTAGE ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-2290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-494-0646
-----------------------------------------------------
Fax | 330-494-9181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30022586
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------