=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679640338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN JOE HALLGARTH D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 08/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 E STREETSBORO ST
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-650-1119
-----------------------------------------------------
Fax | 330-650-0836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5999 NICHOLSON DR
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-650-5025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 30-01-9885
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------