Provider Demographics
NPI:1003933847
Name:HALL, DWAYNE PRESTON (DDS)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:PRESTON
Last Name:HALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3944 DIAMOND RIDGE VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5623
Mailing Address - Country:US
Mailing Address - Phone:719-638-2260
Mailing Address - Fax:719-638-2261
Practice Address - Street 1:5944 STETSON HILLS BLVD
Practice Address - Street 2:STE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2504
Practice Address - Country:US
Practice Address - Phone:719-638-2260
Practice Address - Fax:719-638-2261
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist