Provider Demographics
NPI:1043336597
Name:HALL, LONNIE BRUCE I (DDS)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:BRUCE
Last Name:HALL
Suffix:I
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 1:329 60TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-5497
Mailing Address - Country:US
Mailing Address - Phone:201-868-0070
Mailing Address - Fax:201-869-4030
Practice Address - Street 1:329 60TH ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-5497
Practice Address - Country:US
Practice Address - Phone:201-868-0070
Practice Address - Fax:201-869-4030
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO134118001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0845108Medicaid