Provider Demographics
NPI:1437721834
Name:HALLS, BRANDON (DMD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:HALLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3044
Mailing Address - Country:US
Mailing Address - Phone:208-523-3458
Mailing Address - Fax:
Practice Address - Street 1:12345 S MEMORIAL DR STE 101
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-2570
Practice Address - Country:US
Practice Address - Phone:918-364-4463
Practice Address - Fax:918-364-4465
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice