MEDICARE: VAN HALA DENTAL HUDSON, LLC

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	22586	OH

General Provider Information

NPI Number	:	1437667144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN HALA DENTAL HUDSON, LLC

Provider Business Mailing Address
First Line	:	46 RAVENNA ST STE A6
Second Line	:
City	:	HUDSON
State	:	OH
Zip	:	44236-3058
Country	:	US
Telephone Number	:	330-650-0353
Fax Number	:	330-650-1259

Provider Business Practice Location Address
First Line	:	46 RAVENNA ST STE A6
Second Line	:
City	:	HUDSON
State	:	OH
Zip	:	44236-3058
Country	:	US
Telephone Number	:	330-650-0353
Fax Number	:	330-650-1259

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. BRENT A VAN HALA
Credential	:	DDS
Telephone Number	:	330-650-0353

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	01/16/2018

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