Provider Demographics
NPI:1588656128
Name:HALL, JOHN ROBERT (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:HALL
Suffix:
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 1:3063 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3530
Mailing Address - Country:US
Mailing Address - Phone:765-935-3073
Mailing Address - Fax:
Practice Address - Street 1:1004 OAK DRIVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-935-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120066021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100354300AMedicaid
IN000000083630OtherANTHEM ID NUMBER
IN903140AMedicare ID - Type UnspecifiedMEDICARE ID NUMBER
INT83598Medicare UPIN