Provider Demographics
NPI:1578635538
Name:HALL, WILLIE G JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:G
Last Name:HALL
Suffix:JR
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 1:12164 CENTRAL AVE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1944
Mailing Address - Country:US
Mailing Address - Phone:301-249-8885
Mailing Address - Fax:301-249-0761
Practice Address - Street 1:12164 CENTRAL AVE
Practice Address - Street 2:SUITE 221
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-1944
Practice Address - Country:US
Practice Address - Phone:301-249-8885
Practice Address - Fax:301-249-0761
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2013-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD71191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice