MEDICARE: DOUGLAS R HALLORAN DDS INC

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	122300000X	Dentist	43532	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B43532 01	OTHER	CA	DENTI CAL

General Provider Information

NPI Number	:	1386631349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS R HALLORAN DDS INC

Provider Business Mailing Address
First Line	:	1100 W SHAW AVE
Second Line	:	STE 146
City	:	FRESNO
State	:	CA
Zip	:	93711-3708
Country	:	US
Telephone Number	:	559-224-9925
Fax Number	:	559-224-4478

Provider Business Practice Location Address
First Line	:	1100 W SHAW AVE
Second Line	:	STE 146
City	:	FRESNO
State	:	CA
Zip	:	93711-3708
Country	:	US
Telephone Number	:	559-224-9925
Fax Number	:	559-224-4478

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DOUGLAS RAY HALLORAN
Credential	:	DDS
Telephone Number	:	559-224-9925

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	08/22/2020

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