MEDICARE: KEVIN J. HALLGARTH, D.D.S., 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30-01-9885	OH

General Provider Information

NPI Number	:	1497822167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN J. HALLGARTH, D.D.S., INC.

Provider Business Mailing Address
First Line	:	5999 NICHOLSON DR
Second Line	:
City	:	HUDSON
State	:	OH
Zip	:	44236-4409
Country	:	US
Telephone Number	:	330-650-5025
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 E STREETSBORO ST
Second Line	:
City	:	HUDSON
State	:	OH
Zip	:	44236-3048
Country	:	US
Telephone Number	:	330-650-1119
Fax Number	:	330-650-0836

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEVIN JOE HALLGARTH
Credential	:	D.D.S.
Telephone Number	:	330-650-1119

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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