Provider Demographics
NPI:1093798712
Name:HALL, BRUCE KENNETH (DMD MAGD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:KENNETH
Last Name:HALL
Suffix:
Gender:M
Credentials:DMD MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6216A
Mailing Address - Street 2:NAVAL HOSPITAL BEAUFORT, ATTN:PROF AFFAIRS COORDINATOR
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6148
Mailing Address - Country:US
Mailing Address - Phone:843-228-5577
Mailing Address - Fax:843-228-5196
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:NAVAL HOSPITAL BEAUFORT, ATTN:PROF AFFAIRS COORDINATOR
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-5577
Practice Address - Fax:843-228-5196
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4944122300000X
VA0401005478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN