Provider Demographics
NPI:1154851681
Name:HALL, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0650 SW LOWELL ST APT 427
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4466
Mailing Address - Country:US
Mailing Address - Phone:971-645-2555
Mailing Address - Fax:
Practice Address - Street 1:14240 HORIZON BLVD # A
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-8582
Practice Address - Country:US
Practice Address - Phone:915-852-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist