Provider Demographics
NPI:1679640338
Name:HALLGARTH, KEVIN JOE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOE
Last Name:HALLGARTH
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 1:5999 NICHOLSON DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4409
Mailing Address - Country:US
Mailing Address - Phone:330-650-5025
Mailing Address - Fax:
Practice Address - Street 1:46 E STREETSBORO ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236
Practice Address - Country:US
Practice Address - Phone:330-650-1119
Practice Address - Fax:330-650-0836
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-98851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30-01-9885OtherOHIO DENTAL LICENSE NUMBE