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General NPI Number Information
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NPI Number | 1427556984
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Entity Type | Organization
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Legal Business Name | VAN HALA DENTAL GROUP LLC
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Dates
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Enumeration Date | 01/30/2018
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Last Update Date | 01/30/2018
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Provider Practice Location Address
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Address Line | 1515 PORTAGE ST NW # 1
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City | NORTH CANTON
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State | OH
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Zip | 44720-2290
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Country | US
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Telephone | 330-494-0646
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Fax |
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Provider Business Mailing Address
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Address Line | 1515 PORTAGE ST NW # 1
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City | NORTH CANTON
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State | OH
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Zip | 44720-2290
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Country | US
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Telephone | 330-494-0646
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. BRENT ADDISON VAN HALA
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Credential | DDS
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Telephone | 330-494-0646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30022586
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License Number State | OH
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