Provider Demographics
NPI:1194199117
Name:HALLGREN, KEVIN M (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:HALLGREN
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4019 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2798
Mailing Address - Country:US
Mailing Address - Phone:269-349-9684
Mailing Address - Fax:
Practice Address - Street 1:4019 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2798
Practice Address - Country:US
Practice Address - Phone:269-349-9684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010214511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics