MEDICARE: DR. GARY WAYNE HALL D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN0012157	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	64709	OTHER	FL	BLUE CROSS OF FLORIDA
2	809857	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1336257187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY WAYNE HALL D.D.S.

Provider Business Mailing Address
First Line	:	908 PALM BLVD S
Second Line	:
City	:	NICEVILLE
State	:	FL
Zip	:	32578-2603
Country	:	US
Telephone Number	:	850-729-1223
Fax Number	:	850-678-6086

Provider Business Practice Location Address
First Line	:	908 PALM BLVD S
Second Line	:
City	:	NICEVILLE
State	:	FL
Zip	:	32578-2603
Country	:	US
Telephone Number	:	850-729-1223
Fax Number	:	850-678-6086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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