=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437667144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAN HALA DENTAL HUDSON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2018
-----------------------------------------------------
Last Update Date | 01/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 RAVENNA ST STE A6
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-650-0353
-----------------------------------------------------
Fax | 330-650-1259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 RAVENNA ST STE A6
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-650-0353
-----------------------------------------------------
Fax | 330-650-1259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. BRENT A VAN HALA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 330-650-0353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22586
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------