MEDICARE: HALE FAMILY DENTISTRY CORP

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	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912569492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALE FAMILY DENTISTRY CORP

Provider Business Mailing Address
First Line	:	4116 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6977
Country	:	US
Telephone Number	:	260-482-3759
Fax Number	:	260-482-3750

Provider Business Practice Location Address
First Line	:	4116 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6977
Country	:	US
Telephone Number	:	260-482-3759
Fax Number	:	260-846-6641

Authorized Official
Title or Position	:	MANAGER
Name	:	CASSANDRA HALE
Credential	:
Telephone Number	:	260-482-3759

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	05/01/2023

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Directions to “HALE FAMILY DENTISTRY CORP ” Practice Location

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